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Nursing HomeMedicaid Investigative

Oregon Care Center

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

501 Monroe, Oregon, MO 6447360 bedsLicensed & Active
2/5
Medicare
Inspection
Quality
Staffing
Google rating
4.7/5

based on 11 Google reviews

5
4
3
2
1
Oregon Care Center Nursing Home in Oregon, MO — Street View
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7/ 10
critical Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Abuse citation on record
  • Low overall rating (1/5 stars)
  • Low staffing rating (1/5 stars)
  • High staff turnover (78%)
  • High RN turnover (80%)

Bottom 25% in MO · Critically understaffed (RN) · Very high staff turnover · Worst in PRIME HEALTHCARE MANAGEMENT chain · No penalties on record · Very few deficiencies · Abuse citation

Source: Medicare data

What this means for your family

Oregon Care Center is highly recommended for its compassionate nursing staff and effective rehabilitation services. While the building is older, the facility is well-maintained and clean, making it a reliable choice for long-term care or recovery.

Google Reviews

Google Reviews

11 reviews on Google
Oregon Care Center is highly regarded by residents and families for its compassionate staff and effective rehabilitation programs. While the facility building is noted to be aging, reviewers consistently praise the cleanliness and the genuine care provided by the nursing team.

Quality Themes

Tap a score for details
FoodN/AStaff10.0Clean9.0ActivitiesN/AMedsN/AMemoryN/AComms9.0ValueN/A

Strengths

  • Compassionate and personable nursing staff
  • Effective rehabilitation programs
  • Clean and well-maintained environment

Concerns

  • Aging building infrastructure (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

2344.02014(1)5.02017(2)5.02019(1)5.02020(1)5.02022(2)4.52024(4)5.02025(2)

Distribution · 13 analyzed

5
11
4
1
3
1
2
0
1
0

How They Respond to Reviews

0%response rate

Questions for Your Tour

  • 1I noticed the building has a classic, older feel; what kind of maintenance or renovation plans do you have in place to keep the facility updated and comfortable for residents?
  • 2Given the current staffing levels, how do you ensure that each resident receives consistent, personalized attention throughout the day and night?
  • 3I’ve read such wonderful things about your rehabilitation team; could you share how they collaborate with the nursing staff to support a resident’s recovery goals?
  • 4With your focus on maintaining a clean and welcoming environment, what steps are taken to ensure the facility stays well-maintained for the 60 residents living here?
  • 5How does your team handle medical emergencies or sudden changes in a resident's health status, especially during evening or weekend hours?
  • 6What are some of the most popular daily activities or social programs that help residents feel connected and engaged with one another?

Personalized based on this facility's data


Key Review Excerpts

I have been a resident here since September 20th, 2024, and this is by far the best nursing home I've been to.

Long-term resident · 2024★★★★★

My grandfather, who is also one of my best friends, is at this facility and I can't say enough good things about the ladies who work there with him. They are always extremely personable and helpful when we are there to visit and always have great things to say about him.

Grandchild of resident · 2020★★★★★

They have the best rehab program.

Rehab patient · 2025★★★★★
Source: 11 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.37hrs
50%
Registered nurses for medical care
Total Nursing
3.07hrs
75%
All nurses + aides combined
Staff Turnover
77%
Lower is better (< 30% = good)
RN Turnover
100%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 16 measures

Medicare Rating
1/ 5
Better Than Avg

5

measures

Worse Than Avg

6

measures

Mixed Results

5

measures

Long-Stay Residents
😔

Residents with depression symptoms

↓ Lower is better
This Facility2.6%
Better than Avg
Here
2.6%
US
12.1%
MO
16.7%
Holt
3.1%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility30.6%
Worse than Avg
Here
30.6%
US
19.5%
MO
25.4%
Holt
24.9%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility12.9%
Better than Avg
Here
12.9%
US
15.3%
MO
18.9%
Holt
21.7%
🦠

Residents who got a urinary tract infection

↓ Lower is better
This Facility9.0%
Worse than Avg
Here
9.0%
US
1.6%
MO
2.5%
Holt
1.4%
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility17.6%
Mixed vs Avgs
Here
17.6%
US
15.5%
MO
23.6%
Holt
10.7%
⚠️

Residents who fell and were seriously hurt

↓ Lower is better
This Facility9.5%
Worse than Avg
Here
9.5%
US
3.2%
MO
4.1%
Holt
5.4%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility43.5%
Worse than Avg
Here
43.5%
US
81.8%
MO
65.9%
Holt
84.8%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
1.6%
MO
2.2%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

7deficiencies
Near state avg (12.0)
5 complaint-triggered

This facility has concerning patterns with five families filing complaints that triggered federal investigations, including serious issues with abuse protection and nursing staffing requirements. The most recurring problems involve medication management, fire safety systems, and resident care planning. While the facility corrects most deficiencies when cited, the repeated complaints and recent issues with dietary staffing and resident protection suggest ongoing challenges with consistent quality care.

Dec 4, 2025Routine
9
0324Potential for harm · WidespreadCorrected

Smoke Deficiencies

Provide properly protected cooking facilities.

0353Potential for harm · WidespreadCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0552Potential for harm · PatternCorrected

Resident Rights Deficiencies

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

0583Potential for harm · PatternCorrected

Resident Rights Deficiencies

Keep residents' personal and medical records private and confidential.

0584Potential for harm · PatternCorrected

Resident Rights Deficiencies

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.

0756Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0644Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

0761Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Feb 6, 2025Complaint
1
0600Potential for harm · IsolatedResolved (past non-compliance)

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Nov 21, 2024Routine
3
0801Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0741Potential for harm · IsolatedCorrected

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Nov 21, 2024Complaint
1
0600Potential for harm · IsolatedResolved (past non-compliance)

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Aug 21, 2024Complaint
2
0761Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Aug 2, 2024Complaint
1
0727Potential for harm · IsolatedCorrected

Nursing and Physician Services Deficiencies

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Ownership & Operations

Who Operates This Facility

Owner / Operator

Oregon Care Center

Organization Type

for profit

Chain Affiliation

Chain Name

Prime Healthcare Management

Chain Size

10 facilities nationwide

Chain avg rating: 1.3/5 · Rank 4 of 11 (Worst)

Ownership & Management

Owners

Undisclosed

Ownership Data Not Available · Organization

Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

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