Cycle 1
Health 2025-02-13 · Fire 2025-02-13
9 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
La Grande, OR
La Grande Post Acute Rehabilitation
3-star overall rating with 3-star inspections with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
91 Aries Lane, La Grande, OR
(541) 963-8678
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
76
Certified beds
Average residents
28
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Evergreen Healthcare Group
Operator or chain grouping
Approved since
1989-11-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
41 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.87
Registered nurse staffing · state 0.68 · national 0.68
LPN hours / resident day
0.41
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
3.39
Nurse aide staffing · state 3.37 · national 2.35
Total nurse hours
4.68
All reported nurse hours · state 4.95 · national 3.89
Licensed hours
1.29
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
4.20
Weekend nurse staffing · state 4.39 · national 3.43
Weekend RN hours
0.67
Weekend registered nurse coverage · state 0.44 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.89
CMS adjusted RN staffing hours
Adjusted total hours
4.79
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 53% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,657
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.48
Composite VBP score used to determine payment impact.
Payment multiplier
1.0022
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.83
Baseline 18.05% · Performance 18.27% · Measure score 6.83 · Achievement 6.83 · Improvement 0
Healthcare-associated infections
0
Baseline 7.18% · Performance 8.98% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
7.19
Baseline 45.95% · Performance 34.29% · Measure score 7.19 · Achievement 7.19 · Improvement 5.03
Adjusted total nurse staffing
5.38
Baseline 4.35 hours · Performance 4.61 hours · Measure score 5.38 · Achievement 5.38 · Improvement 1.29
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.22% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 117 · Observed rate 5.13% · Lower 95% interval 6.04% |
| Discharge to community | 50.67% |
50.57%
0.1 pts better
|
No Different than the National Rate · Eligible stays 116 · Observed rate 48.28% · Lower 95% interval 43.9% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 94.74% |
95.27%
0.5 pts worse
|
Numerator 72 · Denominator 76 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 76 |
| Discharge self-care score | 16.39% |
53.69%
37.3 pts worse
|
Numerator 10 · Denominator 61 |
| Discharge mobility score | 36.07% |
50.94%
14.9 pts worse
|
Numerator 22 · Denominator 61 |
| Pressure ulcers or injuries, new or worsened | 1.32% |
2.29%
1 pts better
|
Numerator 1 · Denominator 76 · Adjusted rate 1.06% |
| Healthcare-associated infections requiring hospitalization | 8.98% |
7.12%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 71 · Observed rate 11.27% · Lower 95% interval 4.92% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 49 |
| Staff flu vaccination coverage | 50% |
42%
8 pts better
|
Numerator 36 · Denominator 72 |
| Discharge function score | 34.43% |
56.45%
22 pts worse
|
Numerator 21 · Denominator 61 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 97.78% |
96.28%
1.5 pts better
|
Numerator 44 · Denominator 45 |
| Resident COVID-19 vaccinations up to date | 33.33% |
25.2%
8.1 pts better
|
Numerator 14 · Denominator 42 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 81.0% |
95.5%
14.5 pts worse
|
93.4%
12.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 47.6% · Q2 83.3% · Q4 100.0% · 4Q avg 81.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.7% |
95.2%
3.5 pts worse
|
95.5%
3.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.2% |
2.4%
1.2 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q4 5.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 13.4% |
4.7%
8.7 pts worse
|
11.4%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 4.3% · Q4 20.0% · 4Q avg 13.4% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
5.0%
5 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.2% |
12.5%
5.3 pts better
|
19.6%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.5% |
14.7%
2.2 pts better
|
16.7%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.3% |
15.8%
7.5 pts worse
|
14.9%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.1% |
1.7%
1.4 pts worse
|
1.0%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 2.6% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
2.0%
0.8 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.4% |
22.2%
5.2 pts worse
|
19.8%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.4% |
| Percentage of long-stay residents with pressure ulcers | 6.3% |
6.5%
0.2 pts better
|
5.1%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 8.9% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 65.8% |
85.4%
19.6 pts worse
|
81.7%
15.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 64.3% · Q2 60.8% · Q3 64.9% · Q4 72.1% · 4Q avg 65.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 27.0% |
15.1%
11.9 pts worse
|
12.0%
15 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.0% · Observed 25.0% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.7%
1 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 78.8% |
81.2%
2.4 pts worse
|
79.7%
0.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 78.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.8% |
21.6%
3.8 pts better
|
23.9%
6.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.8% · Observed 17.9% · Expected 23.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-06 · Fire 2023-10-06
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2022-10-21 · Fire 2022-10-21
9 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-13
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-02-26
F · Potential for more than minimal harm
2025-02-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-02-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-14
D · Potential for more than minimal harm
2025-02-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-02-26
F · Potential for more than minimal harm
2023-10-06
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-11-17
F · Potential for more than minimal harm
2023-10-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-06
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-11-17
D · Potential for more than minimal harm
2022-10-21
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-21
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-11-18
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-02
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-04-02
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-18
F · Potential for more than minimal harm
2025-02-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-21
E · Potential for more than minimal harm
2025-02-13
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-03-21
E · Potential for more than minimal harm
2025-02-13
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-13
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-13
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-13
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-03-21
E · Potential for more than minimal harm
2023-10-06
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-06
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-06
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-06
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-06
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-06
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-06
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-06
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-06
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-06
F910 · Environmental Deficiencies
Health
Ensure resident rooms meet each resident's needs.
Corrected 2023-11-17
E · Potential for more than minimal harm
2022-10-21
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2022-11-18
E · Potential for more than minimal harm
2022-10-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-11-18
E · Potential for more than minimal harm
2022-10-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-11-18
E · Potential for more than minimal harm
2022-10-21
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-21
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-21
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-21
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2022-11-18
Penalties and ownership
What sits behind the stars
Ownership
Chernoff, Linda
Operational/Managerial Control · Individual
Couve Financial Services LLC
Operational/Managerial Control · Organization
Couve Healthcare Consulting LLC
Operational/Managerial Control · Organization
La Grande SNF Operations, LLC
Operational/Managerial Control · Organization
Lemmon, Tyler
Operational/Managerial Control · Individual
Morris, Christopher
Operational/Managerial Control · Individual
Odenthal, Jason
Operational/Managerial Control · Individual
Perlman, Harold
Operational/Managerial Control · Individual
Pnw 12 Opco Management LLC
Operational/Managerial Control · Organization
Pnw 12 SNF Consulting LLC
Operational/Managerial Control · Organization
Spielman, Shimon
Operational/Managerial Control · Individual
Yenowitz, Yitzchok
Operational/Managerial Control · Individual
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#2
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3-star overall rating with 2-star inspections with abuse icon flag with $8,278 in total fines with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Washington State Walla Walla Veterans Home
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5-star overall rating with 4-star inspections with 11 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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