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 Mt Angel Health And Rehabilitation during CMS and state inspections, most recent first.
A resident's credit and debit cards were secured in a medication cart by an RN after the resident's death, but the cards went missing after an LPN took over the shift. The LPN displayed unusual behavior and did not return to work, and the cards were never recovered. Law enforcement and the resident's power of attorney were notified.
A resident with dementia and schizoaffective disorder received incorrect medications on two occasions due to staff errors. An RN and an LPN each administered medications intended for other residents, including clonazepam, Depakote, and Clozaril, among others. These errors were acknowledged by the staff, and the physician was notified.
The facility failed to provide written bed hold notifications to two residents or their representatives during hospital transfers. One resident, admitted with depression and diabetes, and another with anxiety and diabetes, were transferred multiple times without receiving the required notifications. Staff confirmed the absence of these notifications.
A resident with quadriplegia fell out of bed and fractured their shoulder due to inadequate supervision and failure to follow the care plan. An agency CNA, on her first shift, did not review the care plan and was misinformed about the resident's assistance needs. The CNA recognized the unsafe positioning but did not seek help, leading to the fall. The facility's DNS confirmed the fall was avoidable, citing lack of peer-to-peer reporting and care plan review as contributing factors.
A facility failed to address pressure ulcer risk factors in a resident's care plan, leading to a Stage 3 pressure injury from an ostomy belt. The resident, with a history of skin breakdown and pressure injuries, often refused ADL and ostomy care, which was not documented in the care plan. Staff reported the resident's ostomy belt was too tight, causing skin issues, and a risk versus benefit form was not completed to address care refusals.
The facility failed to protect a resident from sexual abuse by another resident. Despite staff interventions, the resident was inappropriately touched during breakfast, causing psychosocial harm and increased distress. The offending resident had a history of inappropriate sexual behavior and was supposed to be continuously supervised.
Failure to Protect Resident's Property from Misappropriation
Penalty
Summary
A resident with a diagnosis of diabetes was admitted to the facility in March 2024. After the resident passed away at the hospital, a registered nurse (RN) collected the resident's personal belongings, including six credit and debit cards, and secured them in the narcotic lock box within the medication cart. The RN informed the next nurse, an LPN, about the cards being locked in the cart. Subsequently, the cards went missing and were not found during a later check by the RN. Interviews and record reviews revealed that the LPN who took over the shift was acting unusually and did not return to work after the incident. Other staff members confirmed the LPN's odd behavior and lack of task completion during the shift. The resident's power of attorney was notified of the missing cards, and law enforcement was contacted. The facility administrator confirmed that the cards were missing and not recovered.
Medication Errors in Resident Care
Penalty
Summary
The facility failed to ensure physician orders were followed for a resident, leading to medication errors on two separate occasions. The first incident occurred when an RN administered medications intended for another resident to Resident 10, who had diagnoses including dementia and schizoaffective disorder. The medications administered in error included clonazepam, Depakote, docusate sodium, gabapentin, metoprolol, levothyroxine, and clozapine. The RN was unable to recall the name of the resident whose medications were mistakenly given to Resident 10. The second incident involved an LPN who administered medications intended for another resident to Resident 10. The medications given in error included clonazepam, Clozaril, lamotrigine, furosemide, and levothyroxine. Both incidents were acknowledged by the respective staff members involved, and the physician was notified of the errors. These errors placed the resident at risk for adverse medication side effects.
Failure to Provide Bed Hold Notifications
Penalty
Summary
The facility failed to provide written bed hold notifications to residents or their representatives at the time of transfer to the hospital, as required. This deficiency was identified for two residents who were reviewed for hospitalization. Resident 30, admitted in January 2023 with diagnoses including depression and diabetes, was transferred to the hospital on three occasions in 2024. No evidence was found in the resident's health record indicating that a written notice of the facility's bed hold policy was provided during these transfers. Similarly, Resident 38, admitted in August 2022 with diagnoses including anxiety and diabetes, was transferred to the hospital on three occasions in 2024. Again, there was no evidence of a written bed hold policy being provided. Staff confirmed the absence of these notifications for both residents during the identified transfers.
Avoidable Fall Due to Inadequate Supervision and Care Plan Review
Penalty
Summary
The facility failed to prevent an avoidable fall for a resident with quadriplegia and a Stage 4 pressure injury, who was cognitively intact and required assistance with activities of daily living (ADLs). The resident's care plan indicated the need for assistance from one or two staff members for repositioning and mobility. On the day of the incident, an agency CNA, who was working her first shift at the facility, did not review or have access to the care plan and was informed by a nurse that the resident required only one-person assistance for all ADL care needs. The CNA recognized the resident's unsafe positioning but did not seek additional help, leading to the resident falling out of bed and sustaining a right shoulder fracture. The fall investigation revealed that the CNA had multiple interactions with the resident and followed the care plan, but failed to request a second staff member for assistance when the resident's positioning was unsafe. The resident reported being pushed too close to the edge of the bed, resulting in the fall. The CNA stated that the resident refused repositioning before incontinence care, and when she went to gather supplies, the resident slid out of bed. The resident's right arm was caught in the side rail, and although initially not reporting pain, an X-ray later confirmed a fractured right shoulder. The facility's DNS confirmed the fall was avoidable and highlighted the lack of peer-to-peer reporting and care plan review during shift changes as contributing factors.
Failure to Address Pressure Ulcer Risk Factors in Care Plan
Penalty
Summary
The facility failed to adequately identify and address risk factors related to pressure ulcers in the care plan for a resident with a history of skin breakdown and pressure injuries. The resident, who was cognitively intact, had a colostomy and a history of skin issues, including a nonhealing skin graft and a wound around the stoma. Despite these conditions, the care plan did not reflect the resident's history of skin breakdown from the ostomy belt or their refusal of ADL and ostomy care. This oversight placed the resident at risk for further skin breakdown and pressure injuries. The resident had a pattern of refusing care, including ostomy changes and skin assessments, which contributed to the development of a Stage 3 pressure injury from the ostomy belt. Staff members reported that the resident often refused care, preferring to manage the ostomy bag independently, and would ask staff to return later if it was inconvenient. Despite being seen regularly at a wound clinic, the resident's care plan did not include a risk versus benefit form to document the refusals and potential consequences. Interviews with staff revealed that the resident's ostomy belt was often too tight, leading to skin breakdown. Staff were instructed to place pads under the belt to reduce friction, but this was not always effective. The facility's failure to document the resident's refusals and history of skin breakdown in the care plan, as well as the lack of a completed risk versus benefit form, contributed to the development of the pressure injury. The resident eventually stopped using the ostomy belt after the wound was discovered, and new treatment orders were implemented.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse by another resident. Resident 1, who had dementia and required 24-hour supervision, was inappropriately touched by Resident 2 during breakfast. Despite staff interventions, Resident 2 managed to touch Resident 1's private area, causing Resident 1 psychosocial harm and increased distress. Resident 2 had a history of inappropriate sexual behavior towards staff and was supposed to be continuously supervised in public spaces. On the day of the incident, Resident 2 was placed at a table away from other female residents but managed to move closer to Resident 1. Staff 5 observed Resident 2 rubbing Resident 1's thigh and intervened by moving Resident 2 to the hallway. However, Resident 2 returned to the table and was seen rubbing Resident 1's private area. Staff 3 and Staff 5 separated the residents again and took Resident 2 back to her/his room. Resident 1, who was unable to recall the incident due to her/his dementia, exhibited uncharacteristic behavior and expressed concern about someone sneaking into her/his room. The investigation revealed that Resident 2 had a history of sexually inappropriate behavior, including offering money to staff for sexual favors. Despite the care plan requiring two staff members to be present when interacting with Resident 2, the incident occurred, leading to Resident 1's distress. The facility's failure to adequately supervise Resident 2 and protect Resident 1 from sexual abuse was substantiated, resulting in a deficiency report.
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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 Mount Angel
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| French Prairie Nursing & Rehabilitation Center | 6.9 mi | — | 11 | 0 |
| Woodside Post Acute | 11.8 mi | — | 3 | 1 |
| Tierra Rose Care Center | 12 mi | — | 2 | 0 |
| Avamere Court At Keizer | 12.1 mi | — | 19 | 0 |
| Keizer Nursing And Rehabilitation | 12.1 mi | — | 3 | 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.