Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Curry Village Health And Rehab Of Cascadia during CMS and state inspections, most recent first.
Two residents, both cognitively intact but with significant medical histories, were involved in a physical altercation after one resident threatened to harm the other. Despite a request for a room change and intensified monitoring, the facility did not follow its policy for urgent relocation, resulting in one resident physically assaulting the other and both requiring hospital care.
The facility failed to ensure proper food storage, preparation, and handling, risking foodborne illnesses. Observations revealed unlabeled and undated items in refrigerators and freezers, improper use of gloves, and lack of cleanliness in the kitchen. Staff demonstrated inadequate adherence to food safety protocols, and the facility lacked a cleaning schedule.
The facility did not ensure that food for residents on pureed diets was prepared to preserve nutritional value. Pureed cranberry chicken was served, and staff used water to achieve the texture, determining consistency by sight. The culinary manager stated that guidelines from Sysco were used, but the survey team did not receive these. Sysco's guidelines recommend using gravy, sauce, broth, or milk for pureeing and a two-step testing method for texture.
A resident with paralysis of the lower body, who was cognitively intact and had no swallowing difficulties, was observed taking medications without supervision in the dining room. The RN stated the resident preferred to self-administer medications during meals. However, the facility failed to conduct a self-medication administration assessment, as confirmed by the Chief Nursing Officer and Clinical Resource.
A resident with Alzheimer's and diabetes did not receive required assistance with personal hygiene and bathing due to a lack of staff assignment and communication. The resident, who had severe cognitive impairment, was observed with long facial hair and expressed a desire for shaving assistance. Staff were unclear about the process for shaving diabetic residents, and the responsible staff member for bathing assignments had left unexpectedly, leading to the oversight.
The facility failed to prevent unnecessary psychotropic medication use and did not monitor side effects for two residents. One resident received Xanax beyond the prescribed period due to a lack of documentation, while another resident on trazodone was not monitored for side effects as required. Staff interviews confirmed these deficiencies.
A facility failed to maintain a medication error rate below 5%, resulting in a 7.41% error rate. A resident admitted with malnutrition was prescribed Ferrous Sulfate EC and Calcium with Vitamin D. An LPN administered the wrong dose of iron and omitted the Calcium with Vitamin D due to a transcription error on the MAR, which was not caught during order verification.
A resident with incomplete quadriplegia and dementia did not receive the required range of motion (ROM) exercises as outlined in their care plan. The care plan specified passive ROM during morning and evening care, but the task was not included in the current Kardex, leading to staff not performing the exercises. Interviews with staff confirmed the oversight, and the Chief Nursing Officer acknowledged that CNAs were capable of performing ROM but were not doing so.
Failure to Prevent Resident-to-Resident Physical Abuse Following Missed Room Change
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. One resident, who had a history of stroke and lack of coordination and was cognitively intact, made a statement about intending to harm their roommate, who also had cognitive impairment and cancer but was cognitively intact. Following this threat, intensified monitoring with 15-minute checks was initiated, and a room change request was submitted to Social Services. However, there was no follow-up on the room change request, and the mandated relocation did not occur as scheduled. As a result of the facility's failure to adhere to its policy regarding urgent room changes in situations involving threats of resident-to-resident aggression, the resident who made the threat physically assaulted their roommate, causing facial injuries that required emergency room care. Both residents were subsequently sent to the hospital after the incident, and emergency services and police were called. The administrator acknowledged that immediate relocation and physician notification were required when a resident threatens to harm another resident, but these actions were not taken in a timely manner.
Food Safety and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure proper food storage, preparation, and handling, which put residents at risk for foodborne illnesses. During an initial kitchen observation, several items in the walk-in refrigerator and freezer were found without labels or open dates, including various dairy products, meat, and a pie. Additionally, trays of hamburger patties were uncovered, and a cutting board with dark spots was in use. Staff members were observed not following proper procedures, such as not wearing gloves or cleaning thermometers between uses, and there was a lack of knowledge about food storage and glove-wearing policies. Further observations revealed that the issues persisted, with undated and unlabeled items still present in the refrigerators and freezer. Staff members, including the Culinary Manager and Dietary Aids, demonstrated a lack of adherence to food safety protocols, such as wearing gloves and maintaining cleanliness. The facility also lacked a cleaning schedule or audits for the kitchen, contributing to the ongoing deficiencies in food safety and hygiene practices.
Failure to Preserve Nutritional Value in Pureed Diets
Penalty
Summary
The facility failed to ensure that food for residents on pureed texture diets was prepared in a manner that preserved its nutritional value. During an observation of the lunch meal service, it was noted that pureed cranberry chicken was served as a main course. A dietary aide revealed that water was used to create the puree texture, and the consistency was determined by sight. The culinary manager confirmed that the kitchen staff were instructed to use water for pureeing and mentioned that recipes and texture guidelines were sourced from Sysco. However, the survey team did not receive the promised recipes and guidelines. A review of Sysco's website indicated that pureed foods should be mixed with gravy, sauce, broth, or milk, and a two-step testing method should be used to determine the texture before serving.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure a resident was assessed for the ability to self-administer medications, which was observed during dining observations. The resident, admitted in June 2006 with a diagnosis of paralysis of the lower body, was cognitively intact and had no difficulty swallowing as per the quarterly MDS dated January 19, 2025. On January 30, 2025, the resident was observed sitting alone in the dining room with 12 medications placed on a napkin next to their breakfast tray, without staff supervision to ensure the medications were taken. Staff 10, an RN, stated that the resident preferred to take medications while eating and was left alone during meals. Staff 2, the Chief Nursing Officer, and Staff 3, the Clinical Resource, confirmed that a self-medication administration assessment was not completed and was not present in the resident's clinical record. The resident expressed a preference for taking medications independently and confirmed no issues with swallowing or interruptions during meals.
Failure to Provide Required ADL Assistance
Penalty
Summary
The facility failed to ensure that a dependent resident received the required assistance with activities of daily living (ADLs), specifically personal hygiene and bathing. Resident 36, who was admitted with Alzheimer's disease and diabetes, had a severe cognitive impairment as indicated by a BIMS score of six. The resident's care plan required partial to moderate assistance with personal hygiene and bathing. However, documentation revealed that on a scheduled bathing day, the resident was not assigned to a staff member for bathing, and there was no record of the resident being offered or refusing a bath. Additionally, the resident expressed a desire to have facial hair removed, but staff were unaware of the process for residents without an electric razor. Observations and interviews highlighted that the resident had approximately two-inch long facial hair and could not recall the last time they received a shower. Family members were unaware that staff could assist with facial hair removal. Staff interviews revealed confusion about the process for shaving diabetic residents and a lack of communication regarding the assignment of bathing duties. The Chief Nursing Officer acknowledged that the staff member responsible for the bathing assignment sheet had left unexpectedly, resulting in the missed shower for the resident.
Failure to Monitor Psychotropic Medication Use and Side Effects
Penalty
Summary
The facility failed to ensure that residents did not receive unnecessary psychotropic medications and did not adequately monitor for side effects in two cases. Resident 7, who was admitted with an anxiety disorder, had a physician's order for Xanax to be administered every eight hours as needed for anxiety, with a specified duration of 90 days. However, the medication was administered eight times beyond the prescribed end date, as the end date was not documented in the Medication Administration Record (MAR). Staff interviews confirmed that the end date should have been documented in the clinical records. Resident 28, admitted with a diagnosis of cancer, was receiving trazodone daily at bedtime for sleep. The care plan indicated a goal for the resident to be free from adverse reactions such as sedation, agitation, and confusion. However, the MAR and Treatment Administration Record (TAR) did not include monitoring for side effects of the antidepressant. Observations showed the resident was alert and interacting with others, but staff interviews revealed that side effect monitoring was not documented as required. The Chief Nursing Officer and Clinical Resource verified the lack of documentation for monitoring psychotropic side effects.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 7.41% error rate with two errors in 27 opportunities. Resident 92, admitted with a diagnosis of malnutrition, was prescribed Ferrous Sulfate EC 324 mg and Calcium with Vitamin D. However, on the day following admission, an LPN administered the incorrect dose of iron, providing only 45 mg of Slow Iron, and failed to administer the Calcium with Vitamin D. This error occurred because the Calcium with Vitamin D order was not transcribed onto the Medication Administration Record (MAR) by the medical records staff, and the nurse did not catch the omission during the order verification process. The Chief Executive Officer and Chief Nursing Officer were informed of the transcription error, and the medical records staff acknowledged the oversight.
Failure to Provide Required ROM Exercises for Resident
Penalty
Summary
The facility failed to ensure that a resident received the necessary range of motion (ROM) exercises, as outlined in their care plan. Resident 18, who was admitted with incomplete quadriplegia, dementia, and blindness, required assistance with activities of daily living (ADLs) and had functional limitations in ROM for both arms and legs. The care plan, initiated in November 2024, specified that staff should provide passive ROM during morning and evening care. However, the current Kardex, which guides CNAs on resident-specific care, did not include a task for ROM exercises for Resident 18. Interviews with staff revealed a lack of implementation of the care plan's directives. Staff 17, a CNA, stated that ROM tasks would be performed if they were listed on the Kardex, but they were not. Staff 14, an occupational therapist, noted that Resident 18 was discharged from therapy services due to poor pain tolerance and insight, and the facility did not have a restorative aide program. Staff 4, a Resident Care Manager RN, acknowledged that the care plan required ROM exercises, but they were not included in the Kardex, and thus, not performed by the staff. The Chief Nursing Officer confirmed that CNAs were capable of performing ROM but were not doing so for Resident 18.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Brookings
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| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crescent City Care Center | 20.1 mi | — | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.