Missouri ›Oregon

Oregon Care Center

Name: Oregon Care Center
Address: 501 MONROE, Oregon, MO, 64473, US
Telephone: 6604463355

501 Monroe, Oregon, MO 64473 · Holt County · 60 certified beds · avg 49 residents/day · certified since Feb 1, 1996

4/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

2.84

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: 3/5

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.

All citations in the current public record (19)

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
Dec 4, 2025	E · Potential for harm, repeated	The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand.
Dec 4, 2025	E · Potential for harm, repeated	The facility did not keep residents' personal and medical information private and confidential.
Dec 4, 2025	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.
Dec 4, 2025	E · Potential for harm, repeated	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.
Dec 4, 2025	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Dec 4, 2025	D · Potential for harm, one-off	The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need.
Dec 4, 2025	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Feb 6, 2025	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
Nov 21, 2024	F · Potential for harm, facility-wide	The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service.
Nov 21, 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
Nov 21, 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.
Aug 21, 2024	E · Potential for harm, repeated	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint
Aug 21, 2024	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint
Aug 2, 2024	D · Potential for harm, one-off	The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. · from a complaint
Sep 29, 2022	D · Potential for harm, one-off	The facility did not properly notify residents about the balance of money it holds for them, or failed to return those funds when a resident was discharged, evicted, or died.
Sep 29, 2022	D · Potential for harm, one-off	The facility did not properly protect the personal money residents deposited with it for safekeeping.
Sep 29, 2022	D · Potential for harm, one-off	The facility did not update each resident's care assessment at least once every 3 months. These regular check-ins keep the resident's care plan matched to their current condition.
Sep 29, 2022	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Sep 29, 2022	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (3 → 7).

Year	Citations	Worst severity that year
2022	5	D
2024	6	F
2025	8	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)

No fines or payment denials in the published 3-year window.

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

Measure	This facility	Missouri avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	2.84	3.66	3.95	bottom 18% in Missouri; bottom 9% in the U.S.
Registered Nurse hours	0.30	0.49	0.69	bottom 27% in Missouri; bottom 10% in the U.S.
Weekend total nurse staffing	2.68	3.22	3.50	bottom 26% in Missouri; bottom 15% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.27	0.33	0.48	bottom 49% in Missouri; bottom 25% in the U.S.
Total nursing staff turnover (%)	68.8	56.0	45.8	bottom 18% in Missouri; bottom 7% in the U.S.
RN turnover (%)	0.0	47.8	42.9	—

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 3.01, RN 0.32, weekend 2.84. Staffing rating: 1/5.

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: 2/5 · long-stay residents: 2/5 · short-stay residents: —/5

Who owns this facility

For profit - Limited Liability company

Owner / manager	Type	Role	Stake	Since
		Ownership Data Not Available

Questions to ask on your visit

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

"How do you explain health changes and treatment options to residents and their families?"
"How do you protect residents' privacy, both in their medical records and in day-to-day care?"
"Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
"Does a pharmacist review every resident's medications and chart monthly, and how are their concerns acted on?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"How do you identify and arrange specialized services for residents with mental health conditions or disabilities?"
"Can you show me how medications are stored and secured on the units, including controlled drugs?"
"Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
"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
Tiffany Heights	12.1 mi	Mound City, MO	★★☆☆☆	2/5
Laverna Manor Health & Rehabilitation	17.5 mi	Savannah, MO	★★★☆☆	2/5	abuse
Wathena Healthcare & Rehabilitation Center	17.8 mi	Wathena, KS	★★★☆☆	3/5

Compare this facility with the 3 closest →

All facilities in Oregon →

Facility data as of CMS processing date 2026-08-01. CCN 265629.

The Care File

Visit checklist — Oregon Care Center

501 Monroe, Oregon, MO 64473 · 6604463355

Health inspection rating 4/5 · CMS overall 3/5· Fines (3y): $0

Questions for the administrator:

☐ "How do you explain health changes and treatment options to residents and their families?"
☐ "How do you protect residents' privacy, both in their medical records and in day-to-day care?"
☐ "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
☐ "Does a pharmacist review every resident's medications and chart monthly, and how are their concerns acted on?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "How do you identify and arrange specialized services for residents with mental health conditions or disabilities?"
☐ "Can you show me how medications are stored and secured on the units, including controlled drugs?"
☐ "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
☐ "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 265629 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)