Mt Angel Health and Rehabilitation
540 South Main Street · Mount Angel, OR · 97362 · 5038456841
93 certified beds Non profit - Corporation Chain: The Ensign Group
Why this verdict
- 4 citations involved actual harm to residents.
- Staffing hours comfortably above national benchmarks.
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
63% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 4 of 5 Inspections: 4 of 5 Staffing: 4 of 5 Quality measures: 4 of 5
| Total nurse hours / resident-day | 5.31 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.84 | 0.55–0.75 |
| Weekend hours / resident-day | 4.79 | ≈ weekday level |
| Nursing turnover / year | 63% | median 45% |
| Fines (3-yr window) | 2 · $27,967 |
Inspection citations (29 in the current record)
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Potential for harm · D June 20, 2025 · found via complaint
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected May 22, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D February 14, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected March 31, 2025 · Quality of Life and Care
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No harm found · B February 14, 2025
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 March 31, 2025 · Resident Rights
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Actual harm · G September 19, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected October 31, 2024 · Quality of Life and Care
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Potential for harm · D September 19, 2024 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected October 31, 2024 · Quality of Life and Care
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Actual harm · G April 3, 2024 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected May 3, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D March 22, 2024 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected April 30, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D March 22, 2024 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected April 30, 2024 · Quality of Life and Care
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Potential for harm · E September 22, 2023
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 November 10, 2023 · Resident Rights
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Potential for harm · D September 22, 2023
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected November 10, 2023 · Resident Assessment and Care Planning
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Potential for harm · D September 22, 2023
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected November 10, 2023 · Quality of Life and Care
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Potential for harm · D September 22, 2023
Provide appropriate foot care.
Corrected November 10, 2023 · Quality of Life and Care
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Potential for harm · D September 22, 2023
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected November 10, 2023 · Quality of Life and Care
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Potential for harm · D September 22, 2023
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected November 10, 2023 · Pharmacy Service
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Potential for harm · F September 22, 2023
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected November 10, 2023 · Resident Assessment and Care Planning
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Potential for harm · D September 22, 2023 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected May 6, 2023 · Resident Rights
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Potential for harm · D September 22, 2023 · found via complaint
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected November 10, 2023 · Nursing and Physician Services
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Actual harm · G August 2, 2022
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected September 16, 2022 · Quality of Life and Care
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Actual harm · G August 2, 2022
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected September 16, 2022 · Quality of Life and Care
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Potential for harm · D August 2, 2022
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected September 16, 2022 · Resident Rights
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Potential for harm · D August 2, 2022
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected September 16, 2022 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D August 2, 2022
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected September 16, 2022 · Resident Assessment and Care Planning
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Potential for harm · D August 2, 2022
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected September 16, 2022 · Quality of Life and Care
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Potential for harm · D August 2, 2022
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected September 16, 2022 · Quality of Life and Care
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Potential for harm · D August 2, 2022
Provide safe and appropriate respiratory care for a resident when needed.
Corrected September 16, 2022 · Quality of Life and Care
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| September 19, 2024 | Fine | $10,033 |
| March 22, 2024 | Fine | $17,934 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 385018 · certified since January 1, 1967. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.