Inspection Reports for
Mt. Angel Orchard House
550 S MAIN ST, MOUNT ANGEL, OR, 97362
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
16.8 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
151% worse than Oregon average
Oregon average: 6.7 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Complaint Investigation
Capacity: 98
Deficiencies: 2
Date: Oct 24, 2025
Visit Reason
No deficiencies were cited during this complaint and re-licensure survey. Two initial comment citations were noted but not corrected.
Findings
No deficiencies were cited during this complaint and re-licensure survey. Two initial comment citations were noted but not corrected.
Deficiencies (2)
F0000 - INITIAL COMMENTS. Initial comments noted but no deficiencies cited.
M0000 - Initial Comments. Initial comments noted but no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 98
Deficiencies: 4
Date: Jun 20, 2025
Visit Reason
The facility failed to protect residents from misappropriation of property by staff and did not correct the issue by the last visit. Additional deficiencies related to abuse and administrative rules were also not corrected.
Findings
The facility failed to protect residents from misappropriation of property by staff and did not correct the issue by the last visit. Additional deficiencies related to abuse and administrative rules were also not corrected.
Deficiencies (4)
F0000 - INITIAL COMMENTS. Initial comments noted but not corrected.
F0602 - Free from Misappropriation/Exploitation. Facility failed to protect residents' right to be free from misappropriation of property by staff for 1 sampled resident. The deficient practice was identified as past noncompliance and corrected by the facility after identification.
M0000 - Initial Comments. Initial comments noted but not corrected.
M9999 - STATE OF OREGON ADMINISTRATIVE RULES. Abuse related rules referenced but not corrected.
Inspection Report
Complaint Investigation
Capacity: 98
Deficiencies: 5
Date: Feb 14, 2025
Visit Reason
The facility failed to provide written bed hold notification upon hospital transfer and failed to ensure physician orders were followed for medications. Some deficiencies were corrected temporarily but not sustained.
Findings
The facility failed to provide written bed hold notification upon hospital transfer and failed to ensure physician orders were followed for medications. Some deficiencies were corrected temporarily but not sustained.
Deficiencies (5)
F0000 - INITIAL COMMENTS. Initial comments noted but not corrected.
F0625 - Notice of Bed Hold Policy Before/Upon Transfer. Facility failed to provide residents with written bed hold notification at time of hospital transfer for 2 sampled residents. Corrected temporarily but not sustained.
F0684 - Quality of Care. Facility failed to ensure physician orders were followed for 1 sampled resident related to medication errors. Corrected temporarily but not sustained.
M0000 - Initial Comments. Initial comments noted but not corrected.
M9999 - STATE OF OREGON ADMINISTRATIVE RULES. Related to right to return from hospital and nursing services. Not corrected.
Inspection Report
Complaint Investigation
Capacity: 98
Deficiencies: 5
Date: Sep 19, 2024
Visit Reason
The facility failed to identify and reflect risk factors for pressure ulcers, failed to prevent avoidable falls, and failed to provide adequate nursing services and problem resolution. Some deficiencies were corrected but many remained uncorrected at last visit.
Findings
The facility failed to identify and reflect risk factors for pressure ulcers, failed to prevent avoidable falls, and failed to provide adequate nursing services and problem resolution. Some deficiencies were corrected but many remained uncorrected at last visit.
Deficiencies (5)
F0000 - INITIAL COMMENTS. Initial comments noted but not corrected.
F0686 - Treatment/Services to Prevent/Heal Pressure Ulcer. Facility failed to identify and reflect risk factors in care plan related to pressure ulcers for 1 sampled resident. Corrected temporarily but not sustained.
F0689 - Free of Accident Hazards/Supervision/Devices. Facility failed to prevent an avoidable fall resulting in a fractured shoulder for 1 sampled resident. Corrected temporarily but not sustained.
M0000 - Initial Comments. Initial comments noted but not corrected.
M9999 - STATE OF OREGON ADMINISTRATIVE RULES. Related to nursing services and problem resolution. Not corrected.
Inspection Report
Capacity: 54
Deficiencies: 1
Date: Jun 13, 2024
Visit Reason
The findings of the kitchen inspection, conducted 06/13/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
Findings
The findings of the kitchen inspection, conducted 06/13/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
Deficiencies (1)
OAR 411-054-0030 — Residential Care and Assisted Living Facilities for Resident Services - Meals
Inspection Report
Complaint Investigation
Capacity: 98
Deficiencies: 2
Date: May 10, 2024
Visit Reason
No deficiencies were cited during this complaint and licensure survey. Two initial comment citations were noted but not corrected.
Findings
No deficiencies were cited during this complaint and licensure survey. Two initial comment citations were noted but not corrected.
Deficiencies (2)
F0000 - INITIAL COMMENTS. Initial comments noted but no deficiencies cited.
M0000 - Initial Comments. Initial comments noted but no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 98
Deficiencies: 4
Date: Apr 3, 2024
Visit Reason
The facility failed to protect residents from sexual abuse by another resident and failed to follow abuse prevention policies. Some deficiencies were corrected temporarily but not sustained.
Findings
The facility failed to protect residents from sexual abuse by another resident and failed to follow abuse prevention policies. Some deficiencies were corrected temporarily but not sustained.
Deficiencies (4)
F0000 - INITIAL COMMENTS. Initial comments noted but not corrected.
F0600 - Free from Abuse and Neglect. Facility failed to protect resident's right to be free from sexual abuse by another resident. Corrected temporarily but not sustained.
M0000 - Initial Comments. Initial comments noted but not corrected.
M9999 - STATE OF OREGON ADMINISTRATIVE RULES. Related to abuse. Not corrected.
Inspection Report
Complaint Investigation
Capacity: 98
Deficiencies: 5
Date: Mar 22, 2024
Visit Reason
The facility failed to ensure a resident was free from verbal abuse, failed to ensure physician orders were followed for medications, and failed to protect residents from abuse. Some deficiencies were corrected temporarily but not sustained.
Findings
The facility failed to ensure a resident was free from verbal abuse, failed to ensure physician orders were followed for medications, and failed to protect residents from abuse. Some deficiencies were corrected temporarily but not sustained.
Deficiencies (5)
F0000 - INITIAL COMMENTS. Initial comments noted but partially corrected.
F0600 - Free from Abuse and Neglect. Facility failed to ensure a resident was free from verbal abuse in a resident-to-resident altercation. Corrected temporarily but not sustained.
F0684 - Quality of Care. Facility failed to ensure physician orders were followed for medication administration. Corrected temporarily but not sustained.
M0000 - Initial Comments. Initial comments noted but partially corrected.
M9999 - STATE OF OREGON ADMINISTRATIVE RULES. Related to abuse and nursing services. Not corrected.
Inspection Report
Complaint Investigation
Capacity: 98
Deficiencies: 13
Date: Sep 22, 2023
Visit Reason
The facility had multiple deficiencies including failure to treat residents with dignity, inadequate environmental sanitation, incomplete care plans, poor ADL care, inadequate foot care, dialysis emergency kit absence, insufficient nursing staff, delayed pharmacy responses, and failure to protect resident information. Some deficiencies were corrected temporarily but not sustained.
Findings
The facility had multiple deficiencies including failure to treat residents with dignity, inadequate environmental sanitation, incomplete care plans, poor ADL care, inadequate foot care, dialysis emergency kit absence, insufficient nursing staff, delayed pharmacy responses, and failure to protect resident information. Some deficiencies were corrected temporarily but not sustained.
Deficiencies (13)
F0000 - INITIAL COMMENTS. Initial comments noted but not corrected.
F0550 - Resident Rights/Exercise of Rights. Facility failed to ensure staff treated residents with dignity and respect. Corrected temporarily but not sustained.
F0584 - Safe/Clean/Comfortable/Homelike Environment. Facility failed to ensure resident rooms and bathrooms were sanitized and cleaned timely. Corrected temporarily but not sustained.
F0656 - Develop/Implement Comprehensive Care Plan. Facility failed to implement person-centered care plan for foot care. Corrected temporarily but not sustained.
F0677 - ADL Care Provided for Dependent Residents. Facility failed to provide care to maintain grooming and personal hygiene. Corrected temporarily but not sustained.
F0687 - Foot Care. Facility failed to provide appropriate foot care. Corrected temporarily but not sustained.
F0698 - Dialysis. Facility failed to provide emergency kit for dialysis patient. Corrected temporarily but not sustained.
F0725 - Sufficient Nursing Staff. Facility failed to provide sufficient nursing staff to ensure timely call light response. Corrected temporarily but not sustained.
F0756 - Drug Regimen Review, Report Irregular, Act On. Facility failed to follow pharmacy recommendations timely. Corrected temporarily but not sustained.
F0842 - Resident Records - Identifiable Information. Facility failed to protect resident identifiable information and ensure accurate records. Corrected temporarily but not sustained.
M0000 - Initial Comments. Initial comments noted but not corrected.
M0141 - Employees Reference Checks and Verifications. Facility failed to ensure reference checks were completed for new hires. Corrected temporarily but not sustained.
M9999 - STATE OF OREGON ADMINISTRATIVE RULES. Multiple administrative rules referenced related to resident rights, environment, nursing services, pharmaceutical services, and infection control. Not corrected.
Inspection Report
Capacity: 54
Deficiencies: 6
Date: Aug 21, 2023
Visit Reason
The findings of the re-licensure survey conducted 08/21/23 through 08/23/23 and the first re-visit on 10/26/23 are documented. Multiple deficiencies were identified including resident move-in evaluation, medication administration, psychotropic medication parameters, and fire and life safety issues. Some deficiencies were corrected by 09/30/23 while others remained not corrected as of the last visit.
Findings
The findings of the re-licensure survey conducted 08/21/23 through 08/23/23 and the first re-visit on 10/26/23 are documented. Multiple deficiencies were identified including resident move-in evaluation, medication administration, psychotropic medication parameters, and fire and life safety issues. Some deficiencies were corrected by 09/30/23 while others remained not corrected as of the last visit.
Deficiencies (6)
OAR 411-054-0034 (1-6) Resident Move-in and Eval: Res Evaluation
OAR 411-054-0055 (2) Systems: Medication Administration
OAR 411-054-0055 (6) Systems: Psychotropic Medication
OAR 411-054-0090 (1-2) Fire and Life Safety: Safety
OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents
OAR 411-054-0030 — Residential Care and Assisted Living Facilities for Resident Services - Meals
Inspection Report
Capacity: 98
Deficiencies: 3
Date: Jun 13, 2023
Visit Reason
No deficiencies were cited during this focused infection control and other state/federal survey. Initial comments were noted but not corrected.
Findings
No deficiencies were cited during this focused infection control and other state/federal survey. Initial comments were noted but not corrected.
Deficiencies (3)
E0000 - Initial Comments. Initial comments noted but no deficiencies cited.
F0000 - INITIAL COMMENTS. Initial comments noted but no deficiencies cited.
M0000 - Initial Comments. Initial comments noted but no deficiencies cited.
Inspection Report
Capacity: 54
Deficiencies: 1
Date: Mar 23, 2023
Visit Reason
The findings of the kitchen inspection, conducted 03/23/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
Findings
The findings of the kitchen inspection, conducted 03/23/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
Deficiencies (1)
OAR 411-054-0030 — Residential Care and Assisted Living Facilities for Resident Services - Meals
Inspection Report
Complaint Investigation
Capacity: 98
Deficiencies: 16
Date: Aug 2, 2022
Visit Reason
The facility had numerous deficiencies including failure to assess residents for self-medication, failure to protect residents from abuse, inadequate care planning, failure to provide nail care, failure to ensure medication and respiratory equipment availability, failure to prevent pressure ulcers, failure to re-evaluate injuries, failure to provide dental services, failure to ensure food safety, and failure to follow infection prevention and control protocols. Some deficiencies were corrected temporarily but many remained uncorrected at last visit.
Findings
The facility had numerous deficiencies including failure to assess residents for self-medication, failure to protect residents from abuse, inadequate care planning, failure to provide nail care, failure to ensure medication and respiratory equipment availability, failure to prevent pressure ulcers, failure to re-evaluate injuries, failure to provide dental services, failure to ensure food safety, and failure to follow infection prevention and control protocols. Some deficiencies were corrected temporarily but many remained uncorrected at last visit.
Deficiencies (16)
F0000 - INITIAL COMMENTS. Initial comments noted but not corrected.
F0554 - Resident Self-Admin Meds-Clinically Appropriate. Facility failed to assess residents for self-administration of medication. Corrected temporarily but not sustained.
F0600 - Free from Abuse and Neglect. Facility failed to protect residents from abuse. Corrected temporarily but not sustained.
F0657 - Care Plan Timing and Revision. Facility failed to care plan resident preferences related to CPAP and ADL care. Corrected temporarily but not sustained.
F0677 - ADL Care Provided for Dependent Residents. Facility failed to provide nail care. Corrected temporarily but not sustained.
F0684 - Quality of Care. Facility failed to ensure medications and respiratory equipment were available. Corrected temporarily but not sustained.
F0686 - Treatment/Services to Prevent/Heal Pressure Ulcer. Facility failed to ensure pressure injury wounds were appropriately assessed, monitored and treated. Corrected temporarily but not sustained.
F0689 - Free of Accident Hazards/Supervision/Devices. Facility failed to re-evaluate a resident injury after additional symptoms were reported. Corrected temporarily but not sustained.
F0695 - Respiratory/Tracheostomy Care and Suctioning. Facility failed to provide standard care for a CPAP machine. Corrected temporarily but not sustained.
F0756 - Drug Regimen Review, Report Irregular, Act On. Facility failed to ensure pharmacy recommendations were addressed timely. Corrected temporarily but not sustained.
F0791 - Routine/Emergency Dental Services in Nursing Facilities. Facility failed to provide dental services. Corrected temporarily but not sustained.
F0812 - Food Procurement, Store/Prepare/Serve-Sanitary. Facility failed to ensure pasteurized eggs were used for residents ordering undercooked eggs. Corrected temporarily but not sustained.
F0880 - Infection Prevention & Control. Facility failed to ensure appropriate PPE use and glucometer cleaning. Corrected temporarily but not sustained.
M0000 - Initial Comments. Initial comments noted but not corrected.
M0142 - Employees: Nursing Personnel Verification. Facility failed to verify CNA license for new staff. Corrected temporarily but not sustained.
M9999 - STATE OF OREGON ADMINISTRATIVE RULES. Multiple administrative rules referenced related to pharmaceutical services, abuse, care plans, nursing services, dental and dietary services, and infection control. Not corrected.
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