735 South 2nd Street, Creswell, OR 97426 · Lane County · (541) 895-3333
76 certified beds, about 68 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1988
CMS Care Compare ratings, data as of September 1, 2026 · CCN 385182 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on January 30, 2026, inspectors cited 11 health deficiencies (the Oregon average is 9.2, the national average 9.2).
None of its 50 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.
Nurses and nurse aides worked 5.04 hours per resident per day, against 5.03 across Oregon and 3.86 nationally. Registered nurses accounted for 0.38 of those hours.
44.0% of nursing staff left within the year CMS measured (Oregon average 47.4%).
CMS links it to PACS Group, an affiliated group of 275 nursing homes.
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.
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 50 health citations on file.
Inspectors wroteBased on observation and interview it was determined the facility failed to ensure an ice machine had the required air gap for 1 of 2 facility ice machines reviewed for kitchen sanitation. This placed residents at risk for cross contamination and foodborne illness.
Inspectors wroteBased on observation and interview it was determined the facility failed to properly sanitize and store resident care equipment for 1 of 3 halls reviewed for infection control. This placed residents at risk for exposure to blood borne pathogens and cross contamination.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents who wished to self-administer medications were assessed for 1 of 2 sampled resident (#21) reviewed for ADLs. This placed residents at risk for unsafe self-administration of medications.
Inspectors wroteBased on interview and record review it was determined the facility failed to comprehensively complete a baseline care plan within 48 hours of a resident's admission for 3 of 3 sampled residents (#s 76 and 78) reviewed for care plans. This placed residents at risk for unmet needs.
Inspectors wroteBased on interview and record review it was determined the facility failed to implement comprehensive care plans for 3 of 7 sampled residents (#'s 3, 9 and 32) reviewed for unnecessary medications, diarrhea, and hospice. This placed residents at increased risk for unmet needs.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide bathing for 2 of 2 sampled residents (#s 20 and 21) reviewed for ADLs. This placed residents at risk for unmet care needs.
Inspectors wroteBased on observations, interviews, and record review, it was determined the facility failed to obtain physician orders for tracheostomy care in a timely manner for 1 of 2 sampled residents (# 3) reviewed for respiratory services. This placed residents at risk for respiratory complications.
Inspectors wroteBased on observations, interviews, and record review it was determined the facility failed to ensure staff completed competencies prior to caring for a resident with a tracheostomy for 1 of 1 sampled resident (#3) reviewed for respiratory care. This placed residents at risk for respiratory complications.
Inspectors wroteBased on interview and record review it was determined the facility failed to acquire medications resulting in missed doses for 1 of 1 sampled resident (#56) reviewed for pharmacy services. This placed residents at risk for missed medications. Resident 56 was admitted to the facility 1/2026 with diagnoses including a skin infection and wounds. On 1/26/26 at 10:40 AM Resident 56 reported missed medication doses due to the facility not ordering medications before they ran out. On 1/6/26 Resident 56 was prescribed oral antibiotic Rifaximin 550 mg tablets with one tablet given two times a day. The 1/2026 Medication Administration Record revealed missed doses of Rifaximin on 1/8/26, 1/9/26, 1/15/26, 1/16/26, and 1/25/26. Progress notes indicated the Rifaximin was on order 1/8/26, 1/9/26, 1/15/26, 1/16/26, and 1/25/26. [...]
Inspectors wroteBased on interview and record review it was determined the facility failed to provide influenza and pneumococcal vaccines for 1 of 5 sampled residents (#6) reviewed for immunizations. This placed residents at risk for influenza and pneumonia.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide a COVID-19 vaccine for 1 of 5 sampled residents (#13) reviewed for immunizations. This placed residents at risk for COVID-19.
Inspectors wroteBased on interview and record review, it was determined the facility failed to report timely to the State Survey Agency an allegation of injury of unknown source for 1 of 3 sampled residents (#18) reviewed for abuse. This placed residents at risk for abuse.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide a discharge plan for 1 of 3 residents (# 21) reviewed for discharged planning. This place residents at risk for not having a discharge plan.
Inspectors wroteBased on interview and record review, it was determined the facility failed to complete timely MDS assessments for 2 of 7 sampled residents (#s 27 and 34) who were reviewed for catheter use and staffing. This placed residents at risk for unassessed needs.
Inspectors wroteBased on interview and record review the facility failed to update the resident's care plan for 1 of 2 residents (#20) reviewed for abuse. This placed residents at risk for a lack of planned interventions.
Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to provide sufficient staffing to meet the needs of 2 of 4 residents (#17 and 33) during random observations. This placed residents at risk for unmet needs.
Inspectors wroteBased on interview and record review it was determined the facility failed to complete a discharge summary which included a final summary of the resident's status for 3 of 4 sampled residents (#s 2, 4, and 5) reviewed for discharge. This placed residents at risk for an unsafe discharge.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to follow physician orders, provide bowel care, and administer medications timely for 9 of 12 sampled residents (#s 2, 4, 8, 13, 14, 41, 43, 47, 203) reviewed for change of condition, restraints, pain, bowel care, and medication pass. This placed residents at risk for ineffective interventions.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure proper storage and labeling of medication and biologicals for 1 of 2 treatment carts and 1 of 1 medication and biologicals refrigerator reviewed for biologicals and medication storage. This placed residents at risk for reduced efficacy of medication, inaccurate tuberculosis testing, and decreased vaccine efficacy.
Inspectors wroteBased on interview and record review it was determined a resident was not spoken to in a dignified manner for 1 of 3 sampled residents (#47) reviewed for dignity. This placed residents at risk for lack of self-worth.
Inspectors wroteBased on interview and record review it was determined the facility failed to obtain consent for an influenza vaccination for 1 of 5 sampled residents (#16) reviewed for immunizations. This placed residents and responsible parties at risk for lack of informed consent.
Inspectors wroteBased on interview and record review it was determined the facility failed to notify a resident's emergency contact of a hospitalization and a resident's physician for a change of condition for 2 of 6 sampled residents (#s 18 and 47) reviewed for hospitalization and pressure ulcers. This placed residents at risk for lack of family involvement and delayed treatment.
Inspectors wroteBased on interview and record review it was determined the facility failed to respect the resident rights to deliver postal service mail unopened for 1 of 3 (#12) sampled resident reviewed for privacy. This placed residents at risk for lack of privacy and confidentiality.
Inspectors wroteBased on interview and record review it was determined the facility failed to initiate a grievance process for 1 of 2 sampled residents (#16) reviewed for personal property. This placed residents at risk for unaddressed concerns.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident received a bed hold policy for 1 of 2 sampled residents (#47) reviewed for hospitalization. This placed residents at risk for not being informed of their rights to return to the facility.
Inspectors wroteBased on interview and record review it was determined the facility failed to develop a baseline care plan for 1 of 2 sampled residents (#47) reviewed for constipation. This placed residents at risk for unmet care needs.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure safe discharge planning services for 1 of 5 sampled residents (#16) reviewed for unnecessary medications. This placed resident at risk for unsafe discharge.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 1 of 3 sampled residents (#41) reviewed for ADLs. This placed resident at risk for unmet needs.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to assist residents to obtain prescription glasses for 2 of 2 sampled residents (#s 3 and 18) reviewed for vision. This placed residents at risk for impaired vision.
Inspectors wroteBased observation, interview, and record review it was determined the facility failed to prevent pressure ulcers for 1 of 4 sampled residents (#47) reviewed for pressure ulcers. This placed residents at risk for skin injury.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide a splint for 1 of 2 sampled residents (#2) reviewed for mobility. This placed residents at risk for worsening contractures.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide supervision during an outing involving alcohol for 1 of 1 sampled resident (#43) reviewed for change of condition. This placed residents at risk for accidents.
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 2 errors in 39 opportunities resulting in a 5.13 percent error rate. This placed residents at risk for adverse medication side effects.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident understood an arbitration agreement for 1 of 3 sampled residents (#47) reviewed for arbitration. This placed residents at risk for loss of legal rights.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 3 of 3 sampled residents (#s 3, 5 and 6) reviewed for ADLs. This placed resident at risk for unmet needs.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide sufficient staffing to meet the needs of residents for 3 of 4 sampled residents (#s 6, 8 and 9) and 1 of 3 halls (North) reviewed for staffing. This placed residents at risk for unmet needs.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were free from verbal abuse for 2 of 3 sampled residents (#s 4 and 5) reviewed for abuse. This placed residents at risk for abuse.
Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician's orders for 1 of 3 sampled residents (#6) reviewed for catheter. This placed residents at risk for ineffective treatment of her/his infection.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide adequate catheter care for 2 of 3 residents reviewed for catheterization (#s 3 and 6) reviewed for catheter. This placed residents at risk for unmet catheter needs.
Inspectors wroteBased on interview and record review it was determined the facility failed to monitor behaviors related to dementia for 1 of 3 sampled residents (#5) reviewed for abuse. This placed residents at risk for unmet dementia care needs.
Inspectors wroteBased on interview and record review it was determined the facility failed to administer medications as ordered which resulted in a significant medication error for 1 of 3 sampled residents (#2) reviewed for safe medication system. This placed residents at risk for adverse medication consequences.
Inspectors wroteBased on interview and record review it was determined the facility failed ensure physician orders were followed for 3 of 6 sampled residents (#s 33, 42 and 54) reviewed for ADLs, nutrition and dialysis. This placed residents at risk for unmet needs.
Inspectors wrote1. Based on interview and record review it was determined the facility failed to ensure fall investigations were thorough for 3 of 5 sampled residents (#s 15, 41 and 42) reviewed for accidents and care planning. This placed residents at risk for continued falls and neglect of care.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide sufficient staffing to meet the needs of residents for 7 of 9 sampled residents (#s 6, 13, 15, 18, 25, 58 and 202) reviewed for staffing. This placed residents at risk for unmet needs.
Inspectors wroteBased on interview and record review it was determined the facility failed to treat residents with respect and dignity for 2 of 9 sampled residents (#s 13 and 55) reviewed for abuse and hospice. This placed residents at risk for lack of dignity.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to develop a comprehensive care plan for 1 of 1 sampled resident (#202) reviewed for unnecessary medication. This placed residents at risk for unmet needs.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure routine medication was obtained timely for 2 of 6 sampled residents (#s 11 and 41) reviewed for pain and medications. This placed residents at risk for medication withdrawal symptoms.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure pharmacy review recommendations were addressed by the physician for 1 of 5 sampled residents (#15) reviewed for medications. This placed residents at risk for subtherapeutic medication levels.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents were free from a medication error rate less than 5 percent. There were 3 errors in 31 opportunities resulting in a medication error rate of 9.7 percent. This placed residents at risk for adverse medication consequences.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents received coordination for end-of-life care for 1 of 1 sampled resident (#13) reviewed for hospice. This placed residents at risk for a lack of coordination of care.
16 fire safety citations on file: 10 on January 30, 2026, 3 on November 19, 2025, 3 on August 30, 2024.
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
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) | 5.04 | 5.03 | 3.86 |
| Registered nurses | 0.38 | 0.72 | 0.69 |
| All nursing staff on weekends | 4.66 | 4.51 | 3.42 |
| Nurse aides | 3.69 | ||
| Licensed practical nurses | 0.98 | ||
| Nursing staff turnover (share who left in a year) | 44.0% | 47.4% | 45.8% |
| Registered nurse turnover | 66.7% | 51.6% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.20 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
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 January to March 2026, nursing staff hours per resident were 5.20 on weekdays and 4.66 on weekends, 10% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 32.8% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 5.23 in April to June 2025 to 5.04 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 5.04 | 0.38 | 5.20 | 4.66 | 32.8% | 0 of 90 | 68 |
| Oct to Dec 2025 | 5.07 | 0.43 | 5.21 | 4.74 | 39.3% | 0 of 92 | 67 |
| Jul to Sep 2025 | 4.02 | 0.44 | 4.25 | 3.44 | 4.0% | 1 of 92 | 65 |
| Apr to Jun 2025 | 5.23 | 0.51 | 5.46 | 4.66 | 14.3% | 0 of 91 | 61 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Oregon, Jan to Mar 2026 | 4.91 | 0.64 | 5.12 | 4.40 | 6.2% | 0.4% 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
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. If you work here, your report helps start one.
| 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.
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 | 12.6 | 14.9 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.5 | 1.4 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.5 | 2.0 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 4.1 | 2.4 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.0 | 1.4 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 23.6 | 20.6 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 6.7 | 5.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 8.6 | 13.9 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 22.9 | 21.4 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 18.0 | 16.1 | 12.0 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Creswell Post Acute's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (54.2% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
54.2% this home
No different from the national rate
US median of homes 51.5% · Oregon: 52 better, 3 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 59 eligible stays.
11.5% this home
No different from the national rate
US median of homes 10.7% · Oregon: 3 better, 0 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 53 eligible stays.
6.6% this home
No different from the national rate
US median of homes 7.1% · Oregon: 0 better, 0 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 28 eligible stays.
45.0% this home
Median of homes: Oregon59.2% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 20 residents counted.
0.0% this home
Median of homes: Oregon0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 28 residents counted.
0.0% this home
Median of homes: Oregon2.6% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 28 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Oregon98.5% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 14 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: CRESWELL SNF HEALTHCARE LLC. CMS links this home to PACS Group, a group of 275 nursing homes averaging 2.9 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Truist Bank | 5% or greater security interest | Organization | 09/01/2024 | |
| Apt, Frederick | Operational/managerial control | Individual | 05/10/2024 | |
| Bookout, Jessica | Operational/managerial control | Individual | 09/01/2024 | |
| Holman, Rick | Operational/managerial control | Individual | 09/01/2024 | |
| Jergensen, Joshua | Operational/managerial control | Individual | 05/10/2024 | |
| Mitchell, John | Operational/managerial control | Individual | 05/10/2024 | |
| Wallenkampf, Victor | Operational/managerial control | Individual | 09/01/2024 | |
| Nhi-Reit of Idaho LP | Adp of the SNF | Organization | 09/01/2024 | |
| Providence Administrative Consulting Services Inc | Adp of the SNF | Organization | 09/01/2024 | |
| Holman, Rick | Adp of the SNF | Individual | 06/05/2025 | |
| Wallenkampf, Victor | Adp of the SNF | Individual | 06/05/2025 |
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.
Chosen from this home's own inspection record.
These are the official offices in Oregon. NursingHomeClear cannot take or act on complaints.