Mount Angel, OR
2-star overall rating with 2-star inspections with abuse icon flag with $27,967 in total fines with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
540 South Main Street, Mount Angel, OR
(503) 845-6841
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
93
Certified beds
Average residents
73
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 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
RN hours / resident day
0.77
Registered nurse staffing · state 0.68 · national 0.68
LPN hours / resident day
1.12
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
3.49
Nurse aide staffing · state 3.37 · national 2.35
Total nurse hours
5.38
All reported nurse hours · state 4.95 · national 3.89
Licensed hours
1.89
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
4.68
Weekend nurse staffing · state 4.39 · national 3.43
Weekend RN hours
0.52
Weekend registered nurse coverage · state 0.44 · national 0.47
Physical therapist
0.30
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.75
CMS adjusted RN staffing hours
Adjusted total hours
5.26
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
70%
Annual RN turnover · state 53% · national 45%
Total nurse turnover
63%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Program rank
2,114
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
51.67
Composite VBP score used to determine payment impact.
Payment multiplier
1.0061
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
1.4
Baseline 18.53% · Performance 20.78% · Measure score 1.4 · Achievement 1.4 · Improvement 0
Healthcare-associated infections
6.14
Baseline 5.97% · Performance 6.00% · Measure score 6.14 · Achievement 6.14 · Improvement 0
Total nurse turnover
5.46
Baseline 41.18% · Performance 41.35% · Measure score 5.46 · Achievement 5.46 · Improvement 0
Adjusted total nurse staffing
7.67
Baseline 4.57 hours · Performance 5.26 hours · Measure score 7.67 · Achievement 7.67 · Improvement 5.19
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.25% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 104 · Observed rate 11.54% · Lower 95% interval 7.8% |
| Discharge to community | 60.62% |
50.57%
10 pts better
|
Better than the National Rate · Eligible stays 103 · Observed rate 58.25% · Lower 95% interval 51.69% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.57% |
95.27%
3.3 pts better
|
Numerator 69 · Denominator 70 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 70 |
| Discharge self-care score | 33.87% |
53.69%
19.8 pts worse
|
Numerator 21 · Denominator 62 |
| Discharge mobility score | 38.71% |
50.94%
12.2 pts worse
|
Numerator 24 · Denominator 62 |
| Pressure ulcers or injuries, new or worsened | 4.29% |
2.29%
2 pts worse
|
Numerator 3 · Denominator 70 · Adjusted rate 5.34% |
| Healthcare-associated infections requiring hospitalization | 6% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 53 · Observed rate 1.89% · Lower 95% interval 2.94% |
| Staff COVID-19 vaccination coverage | 7.58% |
8.2%
0.6 pts worse
|
Numerator 10 · Denominator 132 |
| Staff flu vaccination coverage | 76.98% |
42%
35 pts better
|
Numerator 97 · Denominator 126 |
| Discharge function score | 46.77% |
56.45%
9.7 pts worse
|
Numerator 29 · Denominator 62 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 63 · Denominator 63 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | 18.18% |
25.2%
7 pts worse
|
Numerator 6 · Denominator 33 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.4
0.2 pts worse
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.7 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
2.5
1.4 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 77.1% |
95.5%
18.4 pts worse
|
93.4%
16.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 70.2% · Q2 66.7% · Q3 82.8% · Q4 89.3% · 4Q avg 77.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.3% |
95.2%
4.9 pts worse
|
95.5%
5.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.4% |
2.4%
2 pts better
|
3.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.8% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 16.0% |
4.7%
11.3 pts worse
|
11.4%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 14.6% · Q3 10.6% · Q4 17.8% · 4Q avg 16.0% |
| Percentage of long-stay residents who lose too much weight | 2.7% |
5.0%
2.3 pts better
|
5.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 2.0% · Q3 2.2% · Q4 0.0% · 4Q avg 2.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.4% |
12.5%
5.9 pts worse
|
19.6%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 18.5% · Q3 18.4% · Q4 23.9% · 4Q avg 18.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.9% |
14.7%
7.2 pts worse
|
16.7%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.6% · Q2 22.6% · Q3 23.5% · Q4 18.8% · 4Q avg 21.9% · 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 | 18.7% |
24.1%
5.4 pts better
|
16.3%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.7% |
15.8%
4.9 pts worse
|
14.9%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.5% · Q2 16.3% · Q3 28.3% · Q4 15.9% · 4Q avg 20.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
1.7%
1 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 1.4% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.5% |
2.0%
1.5 pts worse
|
1.7%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 5.0% · Q3 0.0% · Q4 3.6% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.9% |
22.2%
0.7 pts worse
|
19.8%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.2% · Q2 11.3% · Q3 31.0% · Q4 11.1% · 4Q avg 22.9% |
| Percentage of long-stay residents with pressure ulcers | 6.6% |
6.5%
0.1 pts worse
|
5.1%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 8.3% · Q3 7.5% · Q4 1.4% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 49.7% |
85.4%
35.7 pts worse
|
81.7%
32 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 34.2% · Q2 49.3% · Q3 61.5% · Q4 59.2% · 4Q avg 49.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.9% |
15.1%
0.2 pts better
|
12.0%
2.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.9% · Observed 14.5% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.7%
0.5 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 0.0% · Q4 3.8% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 72.4% |
81.2%
8.8 pts worse
|
79.7%
7.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 72.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.9% |
21.6%
3.7 pts better
|
23.9%
6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.9% · Observed 17.7% · Expected 23.6% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Top issue: Quality of Life and Care (6 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Quality of Life and Care (6 deficiencies)
14 fire-safety deficiencies
Top issue: Emergency Preparedness (8 deficiencies)
Fire safety
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-03-31
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-31
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2023-11-10
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-11-10
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-10
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-11-10
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-11-10
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-10
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-11-10
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-11-10
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-11-10
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-11-10
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2022-09-21
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2022-09-21
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2022-09-21
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2022-09-21
Fire Safety
Provide emergency officials' contact information.
Corrected 2022-09-21
Fire Safety
Provide primary/alternate means for communication.
Corrected 2022-09-21
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-09-21
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-09-21
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-09-21
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-21
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-09-21
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-09-21
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-09-21
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-09-21
Inspection history
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-05-22
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-31
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2025-03-31
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-31
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-31
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-05-03
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-04-30
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-30
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-11-10
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 2023-11-10
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-05-06
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-11-10
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-11-10
Health
Provide appropriate foot care.
Corrected 2023-11-10
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-11-10
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-11-10
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 2023-11-10
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-09-16
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-09-16
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-09-16
Health
Provide and implement an infection prevention and control program.
Corrected 2022-09-16
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-09-16
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-09-16
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 2022-09-16
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-09-16
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-09-16
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-09-16
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 2022-09-16
Health
Provide or obtain dental services for each resident.
Corrected 2022-09-16
Penalties and ownership
Fine · fine $10,033
Fine
Fine · fine $17,934
Fine
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Corporate Officer · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Nearby options
Woodburn, OR
1-star overall rating with 1-star inspections with Special Focus status with $102,802 in total fines with 22 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Molalla, OR
3-star overall rating with 3-star inspections with $60,281 in total fines with 3 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
Salem, OR
4-star overall rating with 4-star inspections with 2 recent health deficiencies
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