Mt Angel Health and Rehabilitation

Name: Mt Angel Health and Rehabilitation
Address: 540 SOUTH MAIN STREET, Mount Angel, OR, 97362, US
Telephone: 5038456841

540 South Main Street, Mount Angel, OR 97362 · Marion County · 93 certified beds · avg 74 residents/day · certified since Jan 1, 1967

Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)

4/5

Health inspection rating (on-site)

Serious findings on record

$27,967

Fines, last 3 years

5.33

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★★☆4/5 · CMS overall rating: 4/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, one-off · Sep 19, 2024 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Oct 31, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Apr 3, 2024 · F-0600 · triggered by a complaint

The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.

Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: May 3, 2024 (Deficient, Provider has date of correction)

All citations in the current public record (22)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Jun 5, 2026	E · Potential for harm, repeated	The facility did not observe each nurse aide's job performance or provide regular training as required.
Jun 5, 2026	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jun 5, 2026	D · Potential for harm, one-off	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Jun 5, 2026	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Jun 5, 2026	D · Potential for harm, one-off	The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline.
Jun 20, 2025	D · Potential for harm, one-off	The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint
Feb 14, 2025	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Feb 14, 2025	B · Minimal risk, repeated	The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave.
Sep 19, 2024	▲ G · Actual harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Sep 19, 2024	D · Potential for harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Apr 3, 2024	▲ G · Actual harm, one-off	The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Mar 22, 2024	D · Potential for harm, one-off	The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Mar 22, 2024	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Sep 22, 2023	F · Potential for harm, facility-wide	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Sep 22, 2023	E · Potential for harm, repeated	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Sep 22, 2023	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint
Sep 22, 2023	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Sep 22, 2023	D · Potential for harm, one-off	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Sep 22, 2023	D · Potential for harm, one-off	The facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults.
Sep 22, 2023	D · Potential for harm, one-off	The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail.
Sep 22, 2023	D · Potential for harm, one-off	The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint
Sep 22, 2023	D · Potential for harm, one-off	The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (2 → 5).

Year	Citations	Serious (G–L)	Worst severity that year
2023	9	0	F
2024	5	2	G ▲
2025	3	0	D
2026	5	0	E

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

2 fines totaling $27,967.

Date	Type	Amount / length
Sep 19, 2024	Fine	$10,033
Mar 22, 2024	Fine	$17,934

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Oregon avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	5.33	5.42	3.95	top 49% in Oregon; top 9% in the U.S.
Registered Nurse hours	0.77	0.78	0.69	top 35% in Oregon; top 30% in the U.S.
Weekend total nurse staffing	4.78	4.85	3.50	bottom 47% in Oregon; top 8% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.51	0.48	0.48	top 30% in Oregon; top 32% in the U.S.
Total nursing staff turnover (%)	60.4	47.4	45.8	bottom 20% in Oregon; bottom 16% in the U.S.
RN turnover (%)	74.2	51.6	42.9	bottom 12% in Oregon; bottom 9% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 5.23, RN 0.76, weekend 4.68. Staffing rating: 4/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: 4/5

Who owns this facility

For profit - Corporation

Owner / manager	Type	Role	Stake	Since
Burnam, Soon	Individual	Corporate Officer	NOT APPLICABLE	09/12/2024
Farnsworth, Stephen	Individual	Corporate Officer	NOT APPLICABLE	09/12/2024
Horn, David	Individual	Managing Control - Governing Body	NOT APPLICABLE	04/01/2025
Horn, David	Individual	Operational/Managerial Control	NOT APPLICABLE	04/01/2025
Horn, David	Individual	ADP of the SNF	NOT APPLICABLE	04/01/2025
Jamil, Fahad	Individual	Managing Control - Governing Body	NOT APPLICABLE	04/01/2025
Jamil, Fahad	Individual	ADP of the SNF	NOT APPLICABLE	04/01/2025
Ross, Steve	Individual	Corporate Officer	NOT APPLICABLE	09/12/2024
Sato, Ami	Individual	Corporate Officer	NOT APPLICABLE	09/12/2024

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
"How often do you evaluate your nurse aides and what ongoing training do they receive?"
"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"What do you do daily to keep residents moving, and how do you help residents at risk of losing mobility?"
"What safeguards do you have to protect residents' money and belongings, and what happens when something goes missing?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
French Prairie Nursing & Rehabilitation Center	6.9 mi	Woodburn, OR	★☆☆☆☆	1/5	SFF
Woodside Post Acute	11.8 mi	Molalla, OR	★★☆☆☆	1/5
Tierra Rose Care Center	12.0 mi	Salem, OR	★★★★★	5/5
Avamere Court at Keizer	12.1 mi	Keizer, OR	★★★★☆	4/5
Keizer Nursing and Rehabilitation	12.1 mi	Keizer, OR	★★★☆☆	3/5
Marquis Hope Village	13.8 mi	Canby, OR	★★★★☆	4/5
Windsor Health and Rehabilitation	13.9 mi	Salem, OR	★★★☆☆	3/5
Salem Transitional Care	15.6 mi	Salem, OR	★★☆☆☆	2/5
Marquis Wilsonville Post Acute Rehab	16.1 mi	Wilsonville, OR	★★★★★	5/5
Avamere Transitional Care at Sunnyside	16.8 mi	Salem, OR	★★☆☆☆	2/5

Compare this facility with the 3 closest →

All facilities in Mount Angel →

Facility data as of CMS processing date 2026-08-01. CCN 385018.

The Care File

Visit checklist — Mt Angel Health and Rehabilitation

540 South Main Street, Mount Angel, OR 97362 · 5038456841

Health inspection rating 4/5 · CMS overall 4/5· Fines (3y): $27,967

Most serious findings on record:

▲ Sep 19, 2024 (F-0689, Actual harm, one-off): The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
▲ Apr 3, 2024 (F-0600, Actual harm, one-off): The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.

Questions for the administrator:

☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
☐ "How often do you evaluate your nurse aides and what ongoing training do they receive?"
☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "What do you do daily to keep residents moving, and how do you help residents at risk of losing mobility?"
☐ "What safeguards do you have to protect residents' money and belongings, and what happens when something goes missing?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 385018 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)