Blue Mountain Care Center
112 East Fifth Street, Prairie City, OR 97869 · Grant County · (541) 820-3341
40 certified beds, about 14 residents a day · Non profit - Corporation · Medicaid since 1974
Certified for Medicaid
Overall
1 of 5
Health inspections
1 of 5
Staffing
Not rated
CMS note: Not enough data available to calculate a star rating.
Quality measures
3 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 38E040 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on October 17, 2025, inspectors cited 18 health deficiencies (the Oregon average is 9.2, the national average 9.2).
None of its 39 health citations since May 2023 was rated as actual harm or immediate jeopardy.
CMS lists no fines against this home in the last three years.
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
1105/23
808/24
1810/25
205/26
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 39 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
27D
5E
7F
Potential for minimal harm
0A
0B
0C
May 28, 2026Complaint inspection · 2 citations
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on interview and record it was determined the facility failed to follow a comprehensive care plan related to transfers for 1 of 4 sampled residents (#4) reviewed for transfers. This placed residents at risk for unsafe transfers.
- D Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on interview and record review it was determined the facility failed to implement interventions related to substance use disorder for 1 of 1 sampled resident (#3) reviewed for safety. This placed residents at risk for uncontrolled substance use disorder.
October 17, 2025Standard inspection, Complaint inspection · 18 citations
- F Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on interview, and record review it was determined the facility failed to ensure a licensed nurse was on duty for 1 of 2 days reviewed for licensed nurse staffing. This placed residents at risk for delayed and unmet medical needs.
- F 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.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a registered nurse was available for at least eight consecutive hours for 3 of 17 days reviewed for RN coverage. This placed residents at risk for delayed nursing assessments.
- F Post nurse staffing information every day.
Inspectors wroteBased on interview and record review it was determined the facility failed to post accurate and complete staffing information and failed to retain required staff postings for 1 of 1 facility reviewed. This placed residents and the public at risk for incomplete and inaccurate staffing information.
- F Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on interview and record review it was determined the facility administration failed to use resources effectively and efficiently to attain or maintain the residents' highest practicable physical, mental and psychosocial well being. Deficient practice was noted related to a lack of staffing, a failure to retain staff postings, infection control, physician visits, social services, and resident rights for 1 of 1 facility reviewed for effective administration.
- F Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Inspectors wroteBased on interview and record review it was determined the facility failed to submit mandatory staffing information based on the payroll data journal and other verifiable and auditable data as required. This placed residents at risk for inaccurate staffing information.
- F Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure a community use glucometer was properly cleaned and sanitized between resident uses, and the facility failed to develop and conduct a risk analysis assessment for potential areas of growth and spread of water-borne pathogens. This placed residents at risk for exposure to water-borne and blood-borne pathogens.
- F Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Inspectors wroteBased on interview and record review it was determined the facility failed to have a qualified and trained infection preventionist in place for 1 of 1 facility reviewed for infection prevention and control. This placed residents at risk for inadequate infection control.
- E Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on interview and record review, it was determined the facility failed to obtain information related to advance directives and health care decisions for 4 of 4 sampled residents (#s 3, 5, 6 and 12) reviewed for advance directives. This placed residents at risk for not having their health care decisions honored.
- E Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure long term residents received physician visits every 90 days for 3 of 4 sampled residents (#s 1, 8 and 11) reviewed for unnecessary medications and nutrition. This placed residents at risk for unassessed needs.
- D Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on interview and record review it was determined the facility failed to inform residents and/or resident's responsible party of the risks and benefits, and to ensure consent was obtained, for the use of psychotropic medications for 1 of 5 sampled residents (#6) reviewed for unnecessary medications. This placed residents at risk for lack of informed consent of psychotropic medications.
- D Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on observation, interview and record review, the facility failed to offer the resident/representative the opportunity to participate in the care planning process for 4 of 5 sampled residents (#s 3, 5, 6 and 13) reviewed for care planning. These failures placed residents at risk for lack of knowledge and input for the care planning process.
- D Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review it was determined the facility failed to report an allegation of abuse to the State Agency (SA) within the mandated timeframe for 1 of 1 sampled resident (#10) reviewed for abuse. This placed residents at risk for abuse.
- D Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review it was determined the facility failed to thoroughly investigate allegations of abuse for 1 of 1 sampled resident (#10) reviewed for abuse. This placed residents at risk for abuse.
- D 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.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure expired biologicals were discarded and temperatures of medication refrigerators were monitored for 1 of 1 treatment cart and 1 of 1 medication room reviewed for medication storage. This placed residents at risk for reduced efficacy of medication.
- D Provide routine and 24-hour emergency dental care for each resident.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure routine dental services were provided for 1 of 2 sampled residents (#3) reviewed for dental care needs. This placed residents at risk for unmet dental needs.
- D Provide or obtain dental services for each resident.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide dental services for 1 of 2 sampled residents (#12) reviewed for dental services. This placed residents at risk for unmet dental needs.
- D Provide or get specialized rehabilitative services as required for a resident.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide therapy services for 1 of 1 sampled resident (#1) reviewed for nutrition. This placed residents at risk for functional decline.
- D Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Inspectors wroteBased on interview and record review it was determined the facility failed to notify hospice services of the resident's death in a timely manner for 1 of 1 sampled resident (#16) reviewed for hospice. This placed residents at risk for a lack of coordination of care upon death.
August 15, 2024Standard inspection · 8 citations
- E Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to maintain a medication error rate of less than five percent. There were five errors in 26 opportunities resulting in a 19 percent error rate. This placed residents at risk for adverse medication side effects.
- D Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure professional standards were followed for 1 of 1 RN (Staff 2) reviewed for medications and pressure ulcers. This placed residents at risk for adverse medication reactions and worsening of wounds.
- D Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide nail care to dependent residents for 2 of 2 sample residents (#s 10 and 11) reviewed for ADLs. This placed residents at risk for lack of grooming and skin impairments.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to implement physician orders upon admission for 1 of 1 sampled residents (#164) reviewed for medications. This placed residents at risk for adverse medication reactions.
- D Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview and record review it was determined the facility failed to initially assess and monitor pressure ulcers for 2 of 2 sampled residents (#s 6 and 8) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers and unassessed treatment needs.
- D Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review it was determined the facility failed to obtain ordered medications timely for 2 of 6 sampled residents (#s 1 and 7) reviewed for medications. This placed residents at risk for not receiving prescribed medications.
- D Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on interview and record review it was determined the facility failed to address pharmacist recommendations in a timely manner for 3 of 5 sampled residents (#s 6, 8 and 12) reviewed for unnecessary medications. This placed residents at risk for unnecessary medication administration.
- D Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure medical records were accurate for 2 of 2 sampled residents (#s 6 and 8) reviewed for pressure ulcers. This placed residents at risk for inaccurate wound measurements.
May 18, 2023Standard inspection · 11 citations
- E Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 2 of 2 sampled CNA staff (#s 5 and 6) reviewed for staffing. This placed residents at risk for a lack of competent staff.
- E Implement a program that monitors antibiotic use.
Inspectors wroteBased on interview and record review it was determined the facility failed to implement an antibiotic stewardship program for 1 of 1 facility reviewed for antibiotic stewardship. This placed residents at risk for developing antibiotic resistance.
- D Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide quarterly statements in writing of Personal Incidental Funds (PIF) for 2 of 2 sampled residents (#s 3 and 5) reviewed for PIFs. This placed residents at risk of being uninformed of financial statements.
- D Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on interview and record review it was determined the facility failed to complete comprehensive assessments for 1 of 5 sampled residents (# 6) reviewed for medication. This placed residents at risk for unassessed needs.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to assess and treat diabetic ulcers for 1 of 1 sampled resident (#1) reviewed for pressure ulcers. This placed residents at risk for worsening skin conditions.
- D Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview and record review it was determined the facility failed to assess and treat pressure ulcers for 1 of 1 sampled resident (#1) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers.
- D Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to have an order in place for the use of a catheter for 1 of 2 sampled residents (#119) reviewed for catheters. This placed residents at risk for urinary tract infections.
- D Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a thorough medication regimen review was completed by the pharmacist monthly for 2 of 2 sampled residents (#s 2 and 4) reviewed for antibiotic use. This placed residents at risk for adverse medication side effects.
- D Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on interview and record review it was determined the facility failed to complete psychotropic drug reviews for 2 of 5 sampled residents (#s 2 and 8) reviewed for medications. This place residents at risk for unnecessary medications.
- D Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure medical records were complete and accurate for 1 of 6 sampled residents (#8) reviewed for medications. This placed residents at risk for incomplete medical records.
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and interview it was determined the facility failed to ensure proper placement of a resident's catheter to prevent infection for 2 of 2 sampled residents (#s 4 and 119) randomly observed for infection control. This placed residents at risk for infection.
Fire safety inspections
20 fire safety citations on file: 10 on October 17, 2025, 8 on August 15, 2024, 2 on May 18, 2023.
Every fire safety citation20 citations
- F Address patient/client population and determine types of services needed.
- F Address subsistence needs for staff and patients.
- F Conduct testing and exercise requirements.
- F Implement emergency and standby power systems.
- F Have approved installation, maintenance and testing program for fire alarm systems.
- F Inspect, test, and maintain automatic sprinkler systems.
- F Have simulated fire drills held at unexpected times.
- F Have generator or other power source capable of supplying service within 10 seconds.
- E Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- D Install proper backup exit lighting.
- F Conduct risk assessment and an All-Hazards approach.
- F Develop Emergency Preparedness policies and procedures.
- F Have approved installation, maintenance and testing program for fire alarm systems.
- F Inspect, test, and maintain automatic sprinkler systems.
- F Have simulated fire drills held at unexpected times.
- F Have generator or other power source capable of supplying service within 10 seconds.
- E Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- D Have proper medical gas storage and administration areas.
- F Conduct testing and exercise requirements.
- F Have simulated fire drills held at unexpected times.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Oregon | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | not reported | 5.03 | 3.86 |
| Registered nurses | not reported | 0.72 | 0.69 |
| All nursing staff on weekends | not reported | 4.51 | 3.42 |
| Nurse aides | not reported | ||
| Licensed practical nurses | not reported | ||
| Nursing staff turnover (share who left in a year) | not reported | 47.4% | 45.8% |
| Registered nurse turnover | not reported | 51.6% | 42.9% |
| Administrators who left | not reported |
CMS note on this home's staffing data: This facility submitted data that did not meet the criteria required to calculate a staffing measure.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In October to December 2025, nursing staff hours per resident were 6.08 on weekdays and 4.82 on weekends, 21% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 53.2% of nursing hours, against 5.3% nationally.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Oct to Dec 2025 | 5.72 | 1.48 | 6.08 | 4.82 | 53.2% | 4 of 92 | 15 |
| United States, Oct to Dec 2025 | 3.76 | 0.62 | 3.93 | 3.34 | 5.3% | 0.5% of days | |
| Oregon, Oct to Dec 2025 | 5.00 | 0.65 | 5.20 | 4.47 | 7.3% | 0.3% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
Staff pay at this home
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.
Official wage estimates for Oregon
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Oregon, all employers | |||
| CNAs (nursing assistants) | $23.96 | $22.83 to $28.40 | 14,800 |
| LPNs and LVNs | $38.69 | $35.11 to $43.60 | 4,260 |
| Registered nurses | $62.02 | $51.55 to $64.63 | 39,730 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Oregon | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 12.5 | 14.9 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 6.4 | 1.4 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.0 | 2.0 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 5.2 | 2.4 | 3.2 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 5.0 | 5.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 8.5 | 13.9 | 15.4 |
Owners and operators
Legal business name: Legal Business Name Not Available.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Ownership data not available |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 10 problems in this area, most recently on May 28, 2026: "Ensure each resident must receive and the facility must provide necessary behavioral health care and services."
- How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 6 problems in this area, most recently on October 17, 2025: "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."
- When is the care plan meeting, and can family attend it?Inspectors cited 5 problems in this area, most recently on May 28, 2026: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured."
- How many nurses and aides work each shift, nights and weekends included?Inspectors cited 5 problems in this area, most recently on October 17, 2025: "Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift."
Oregon contacts for a concern about a nursing home
These are the official offices in Oregon. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Oregon Department of Human Services, Nursing Facility Licensing, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Oregon Office of the Long-Term Care Ombudsman, (800) 522-2602. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: Oregon Licensed Long-Term Care Settings Search, where Oregon publishes its own records on licensed homes.
Common questions
- What is Blue Mountain Care Center's Medicare star rating?
- CMS rates Blue Mountain Care Center 1 out of 5 stars overall, with 1 for health inspections, no for staffing and 3 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Blue Mountain Care Center get at its last inspection?
- 18 health deficiencies at the standard inspection on October 17, 2025. The Oregon average is 9.2.
- Has Blue Mountain Care Center been fined?
- CMS lists no fines in the last three years.
- Does Blue Mountain Care Center accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Blue Mountain Care Center?
- CMS lists 1 owner or manager. Legal business name: Legal Business Name Not Available.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.