Albany, OR

Mennonite Home

3-star overall rating with 3-star inspections with $17,934 in total fines with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

5353 Columbus Street Se, Albany, OR

(541) 928-7232

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

1 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

95

Certified beds

Average residents

35

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1989-08-11

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

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

0.60

Registered nurse staffing · state 0.68 · national 0.68

LPN hours / resident day

1.15

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

4.79

Nurse aide staffing · state 3.37 · national 2.35

Total nurse hours

6.53

All reported nurse hours · state 4.95 · national 3.89

Licensed hours

1.74

RN + LPN hours · state 1.58 · national 1.54

Weekend hours

5.62

Weekend nurse staffing · state 4.39 · national 3.43

Weekend RN hours

0.49

Weekend registered nurse coverage · state 0.44 · national 0.47

Physical therapist

0.08

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

0.67

CMS adjusted RN staffing hours

Adjusted total hours

7.31

CMS adjusted total nurse staffing hours

Case-mix index

1.22

Higher values indicate more complex resident acuity

RN turnover

33%

Annual RN turnover · state 53% · national 45%

Total nurse turnover

31%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

1,351

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

57.36

Composite VBP score used to determine payment impact.

Payment multiplier

1.0125

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0.97

Performance 20.98% · Measure score 0.97 · Achievement 0.97 · This facility did not have sufficient data to calculate a baseline period measure result.

Healthcare-associated infections

5.70

Performance 6.13% · Measure score 5.70 · Achievement 5.70 · This facility did not have sufficient data to calculate a baseline period measure result.

Total nurse turnover

6.28

Baseline 52.03% · Performance 38.03% · Measure score 6.28 · Achievement 6.28 · Improvement 4.65

Adjusted total nurse staffing

10

Baseline 6.66 hours · Performance 6.25 hours · Measure score 10 · Achievement 10 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.73%	10.72% 1 pts worse	No Different than the National Rate · Eligible stays 38 · Observed rate 15.79% · Lower 95% interval 7.68%
Discharge to community	54.5%	50.57% 3.9 pts better	No Different than the National Rate · Eligible stays 43 · Observed rate 51.16% · Lower 95% interval 43.01%
Medicare spending per beneficiary	0.83	1.02 0.2 pts better
Drug regimen review with follow-up	80.95%	95.27% 14.3 pts worse	Numerator 17 · Denominator 21
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 21
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	4.76%	2.29% 2.5 pts worse	Numerator 1 · Denominator 21 · Adjusted rate 8%
Healthcare-associated infections requiring hospitalization	6.13%	7.12% 1 pts better	No Different than the National Rate · Eligible stays 31 · Observed rate 0% · Lower 95% interval 3.36%
Staff COVID-19 vaccination coverage	2%	8.2% 6.2 pts worse	Numerator 3 · Denominator 150
Staff flu vaccination coverage	66.67%	42% 24.7 pts better	Numerator 176 · Denominator 264
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	95.5% 4.5 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	94.4%	95.2% 0.8 pts worse	95.5% 1.1 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 94.4%
Percentage of long-stay residents experiencing one or more falls with major injury	3.2%	2.4% 0.8 pts worse	3.3% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.1% · Q3 3.0% · Q4 3.3% · 4Q avg 3.2% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	3.8%	4.7% 0.9 pts better	11.4% 7.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 7.7% · Q4 7.7% · 4Q avg 3.8%
Percentage of long-stay residents who lose too much weight	2.3%	5.0% 2.7 pts better	5.4% 3.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.3% · 4Q avg 2.3%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	9.1%	12.5% 3.4 pts better	19.6% 10.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 8.7% · Q3 13.0% · 4Q avg 9.1%
Percentage of long-stay residents who received an antipsychotic medication	15.4%	14.7% 0.7 pts worse	16.7% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 15.4% · 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% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	28.7%	24.1% 4.6 pts worse	16.3% 12.4 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 28.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	41.4%	15.8% 25.6 pts worse	14.9% 26.5 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 41.4% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.5%	1.7% 0.2 pts better	1.0% 0.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 0.0% · Q3 0.0% · Q4 3.3% · 4Q avg 1.5% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	5.6%	2.0% 3.6 pts worse	1.7% 3.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 6.1% · Q3 9.1% · Q4 3.3% · 4Q avg 5.6% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	22.1%	22.2% 0.1 pts better	19.8% 2.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 38.0% · Q2 27.1% · Q3 16.0% · Q4 7.4% · 4Q avg 22.1%
Percentage of long-stay residents with pressure ulcers	5.5%	6.5% 1 pts better	5.1% 0.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 8.4% · Q3 4.7% · Q4 2.8% · 4Q avg 5.5% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	90.1%	85.4% 4.7 pts better	81.7% 8.4 pts better	Short Stay · 2024Q4-2025Q3 · Q1 90.0% · Q2 83.9% · Q3 93.3% · Q4 92.5% · 4Q avg 90.1%
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.7% 1.7 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	67.7%	81.2% 13.5 pts worse	79.7% 12 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 67.7%

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-11-21 · Fire 2024-11-21

7 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 2 Health 2023-09-08 · Fire 2023-09-08

8 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

7 fire-safety deficiencies

Top issue: Emergency Preparedness (3 deficiencies)

Cycle 3 Health 2019-01-31 · Fire 2019-01-31

1 health deficiencies

Top issue: Infection Control (1 deficiency)

6 fire-safety deficiencies

Top issue: Emergency Preparedness (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-11-21

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-01-10

E · Potential for more than minimal harm 2024-11-21

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2025-01-10

F · Potential for more than minimal harm 2023-09-08

E13 · Emergency Preparedness Deficiencies

Fire Safety

Develop Emergency Preparedness policies and procedures.

Corrected 2023-10-28

F · Potential for more than minimal harm 2023-09-08

E15 · Emergency Preparedness Deficiencies

Fire Safety

Address subsistence needs for staff and patients.

Corrected 2023-10-28

F · Potential for more than minimal harm 2023-09-08

E18 · Emergency Preparedness Deficiencies

Fire Safety

Establish procedures for tracking staff and patients during an emergency.

Corrected 2023-10-28

F · Potential for more than minimal harm 2023-09-08

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2023-10-28

F · Potential for more than minimal harm 2023-09-08

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-10-28

D · Potential for more than minimal harm 2023-09-08

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-10-28

D · Potential for more than minimal harm 2023-09-08

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2023-10-28

F · Potential for more than minimal harm 2019-01-31

E26 · Emergency Preparedness Deficiencies

Fire Safety

Establish roles under a Waiver declared by secretary.

Corrected 2019-03-22

F · Potential for more than minimal harm 2019-01-31

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2019-03-22

E · Potential for more than minimal harm 2019-01-31

K163 · Construction Deficiencies

Fire Safety

Install noncombustible or limited-combustible interior walls.

Corrected 2019-03-22

E · Potential for more than minimal harm 2019-01-31

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2019-03-22

D · Potential for more than minimal harm 2019-01-31

E24 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures for volunteers.

Corrected 2019-03-22

D · Potential for more than minimal harm 2019-01-31

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2019-03-22

Inspection history

Recent health citations

G · Actual harm 2025-03-04

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 2025-04-23

F · Potential for more than minimal harm 2024-11-21

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 2025-01-10

D · Potential for more than minimal harm 2024-11-21

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2025-01-10

D · Potential for more than minimal harm 2024-11-21

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2025-01-10

D · Potential for more than minimal harm 2024-11-21

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 2025-01-10

D · Potential for more than minimal harm 2024-11-21

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-01-10

D · Potential for more than minimal harm 2024-11-21

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2025-01-10

G · Actual harm 2024-07-24

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 2024-09-12

F · Potential for more than minimal harm 2023-09-08

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-10-28

D · Potential for more than minimal harm 2023-09-08

F553 · Resident Rights Deficiencies

Health

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Corrected 2023-10-28

D · Potential for more than minimal harm 2023-09-08

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2023-10-28

D · Potential for more than minimal harm 2023-09-08

F642 · Resident Assessment and Care Planning Deficiencies

Health

Ensure a qualified health professional conducts resident assessments.

Corrected 2023-10-28

D · Potential for more than minimal harm 2023-09-08

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 2023-10-28

D · Potential for more than minimal harm 2023-09-08

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2023-10-28

D · Potential for more than minimal harm 2023-09-08

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 2023-10-28

D · Potential for more than minimal harm 2019-01-31

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2019-03-22

Penalties and ownership

What sits behind the stars

$9,110 2025-03-04

Fine

Fine · fine $9,110

Fine

$8,824 2024-07-24

Fine

Fine · fine $8,824

Fine