Prestige Post-Acute & Rehab Center McMinnville

The Centers for Medicare and Medicaid Services (CMS) and the state of Oregon routinely conduct surveys and investigations on every nursing facility to ensure that residents are receiving the utmost care. In the event of a violation or deficiency, the surveyor will write a report and produce a directive to ensure the deficiencies and violations are corrected immediately. The nursing facility is given an appropriate amount of time to make improvements or face unwanted legal consequences.

Some facilities have ongoing problems that are based on underlying conditions where the residents receive substandard care. When this occurs, Medicare, Medicaid and the state of Oregon might classify the nursing home as a Special Focus Facility (SFF). This unwanted designation identifies the nursing home as having dangerous and hazardous problems. Also, placing a nursing facility on this federal watchlist triggers additional scheduled surveys and unannounced inspections to determine if any improvements are long-lasting.

In recent months, federal and state nursing home regulators designated Prestige Post-Acute and Rehab Center – McMinnville as a Special Focus Facility. The nursing home has been given the opportunity to make improvements instead of closing their doors or losing their contract to provide care to Medicare and Medicaid patients. Likely, the facility will remain on the federal watch list for months or years until all improvements have been made and verified.

Prestige Post-Acute and Rehab Center – McMinnville (SFF)

The 96-certified bed Medicare/Medicaid-participating nursing facility provides cares and services to residents of McMinnville and Yamhill County, Oregon. The Home is located at:

421 SE. Evans St.
McMinnville OR 97128
(503) 472-3141
Administrator: Chuck Williams

In addition to providing skilled nursing care, this home also offers post-acute and rehabilitation care, memory care, and assisted living and independent living options.


The Centers for Medicare and Medicaid Services and nursing home regulators in the state of Oregon issue fines to a facility with serious violations to eliminate the potential of recurring problems in the future. Over the last three years, Prestige Post-Acute and Rehab Center – McMinnville has been penalized three times including a $2925 fine on February 9, 2015, a $2000 fine on June 2, 2015, and an $11,053 fine on February 10, 2017.

Current Nursing Home Resident Safety Concerns

The federal state agencies in charge of regulating nursing facilities conduct ongoing surveys and investigations to identify dangerous safety concerns and health violations. These agencies post the results of their inspections on the federal website and make the information available to the public through a star-based rating system.

Currently, Prestige Post-Acute & Rehab Center – McMinnville maintains overall a below-average two out of five stars compared to other facilities nationwide. This ranking includes one out of five stars for health inspections, four out of five stars for staffing, and four out of five stars for quality measures. The current health and safety concerns involving this facility are listed below.

  • Failure to Ensure Services Provided by the Nursing Facility Meet Standards of Quality

    In a summary statement of deficiencies dated February 10, 2017, the state investigator noted that the facility had failed to “properly intervene and act upon a resident’s complaint of ongoing respiratory difficulty.” This deficiency involved “the resident’s desire to go to the hospital, to properly notify the physician and accurately and comprehensively document a resident’s assessment according to professional standards.”

    Documentation stated that the resident “experienced complaints of breathing difficulties for approximately three hours before the resident called 911 [on their own and] was transported to the hospital [where they] died later the same day.”

    In a heavily redacted document, it is noted that a witness stated that the resident’s son “received a phone call from [the resident and] that the resident was unable to make [themselves] understood. A facility Certified Nursing Assistant picked up the phone and stated that the resident could not breathe well and wanted to go to the hospital, but the nurse was not going to send the resident.”

    The witness then stated that “they called the facility back and spoke to [a Licensed Practical Nurse] who told him she thought the resident might have an upper respiratory infection or pneumonia did not want the resident to be exposed to other germs at the hospital.” The LPN “told them she would call the physician and ask for a chest x-ray.” However, in the meantime “the resident had called 911 [on their own] and went to the hospital” where the resident later succumbed to their condition.

    The state investigator reviewed the resident’s “clinical record [that] revealed no documentation indicated [that] the resident’s respiratory status was assessed, reassessed, monitored, ordered p.r.n. [as necessary] breathing treatment administered or that a physician was properly notified of the resident’s significant change in condition when the resident complained of shortness of breath at approximately 6:30 AM until approximately 10:00 AM when the resident activated the Emergency Medical Services [on their own].”

  • Failure to Honor a Resident’s Rights to Be Free of Coercion and Reprisal

  • Failure to Protect Every Resident from Physical Punishment, Abuse or Being Separated from Others

  • Failure to Provide Care to Residents in a Way That Keeps and Builds Their Dignity and Respect of Individuality

    In a summary statement of deficiencies dated August 11, 2017, the state investigator noted the facility had failed to “ensure residents were free from physical abuse.” This failure involved one resident at the facility that was “determined to be an Immediate Jeopardy situation, resulting in [a resident] being subjected to physical abuse.”

    In the same summary statement of deficiencies, the state investigator noted the facility’s failure “to promote a resident’s autonomy and choice free of coercion.” This failure by the nursing staff was “determined to be an Immediate Jeopardy situation [that] resulted in a violation of [the resident’s] right to be free of interference, coercion, and reprisal.”

    The surveyor determined that the facility had failed to “ensure residents were treated with respect and dignity.” This deficiency affected seven residents at the nursing home and was “determined to be an Immediate Jeopardy situation, resulted in staff speaking to [a resident] in an undignified manner.”

    The state investigator reviewed the resident’s June 19, 2017, Annual MDS (Minimum Data Set) Section C that indicated the resident had a BIMS (Brief Interview for Mental Status) score of 4. This low score revealed “severe mental impairment.” A review of the resident’s April 19, 2017, In-Room Care Plan indicated that the resident required extensive assistance for locomotion and had “some confusion and forgetfulness; communication” in cognition. The document says, “allow resident time to process and speak – may be slow.”

    The resident’s June 24, 2017, Behavior Symptoms Care Plan indicated the resident “required simple explanations of needs and time to [process their thoughts before responding]. Approach a resident with simple explanations of care and treatment and medication needs prior to providing.” It also stated to “offer [the resident sufficient time for their] thought process [of] questions/expressions [including] any concerns or questions. Validate [their] decisions. Revisit at a later time as safety and care allows.”

    During the early evening hours of August 8, 2017, a Certified Nursing Assistant “was observed [pushing the resident] down the 300 Hallway in a wheelchair. The resident yelled ‘No.’” The CNA stopped in the hallway, attempted to place [the resident process] foot on the wheelchair footrest” when the resident “again yelled ‘No.’” The Certified Nursing Assistant then stated, “I will just drag your feet then, God bless America.”

    The Certified Nursing Assistant continued to push the resident “down the hall with the bottom of [their] foot dragging on the floor.” The CNA continued to push “the resident very fast down the hall toward the nurses’ station” and stated, ‘here comes a bump’ as he went through the double doors by the nurse’s station” and “continued down the hallway toward the dining room.” The resident was then observed “in the hallway by the elevator [with] both feet resting on the footrest.

    The CNA stated in the morning that the resident “didn’t want to put [their] foot up on the footrest.” The CAN “told the resident if [they] didn’t put [their] foot up ‘we are going to have to drag it,’ then the resident had [their] foot down and I told [them] to put it up.”

  • Failure to Allow The Resident to Refuse Treatment Take Part in an Experiment and Formulate Advance Directives

  • Failure to Ensure Every Resident Remained Free from Physical Restraint Unless Needed for Medical Treatment

    In a summary statement of deficiencies dated August 11, 2017, the state investigator noted that the facility had failed to “allow the resident the right to refuse treatment for [medical] care. This failure, determined to be an Immediate Jeopardy situation resulted in staff inserting or attempting to insert [a] cannula against the resident’s wishes while [they were restrained].”

    The investigator reviewed the April 23, 2017, Progress Note written by an LPN indicating that the resident’s “gums appear to have no sign of bleeding, resident minimally cooperative with oral care that shift. The resident started grinding teeth and shaking [their] head when I approached to do oral care [two times].”

    An additional July 1, 2017, Progress Notes revealed that the resident’s cannula “popped out during cares.” An LPN “was attempting to replace it, and the resident was trying to hit her. In Aide restrained the resident’s hand and [the LPN] told the resident [their] combative behavior was inappropriate. The resident flipped [their finger at] the nurse [but] allowed her to complete the treatment. At 3:00 AM, Aides went in to change the resident’s brief and found [the resident] crying.” Additional restraints were used at different times as documented in the resident’ as medical records.

    The investigator noted that the “Progress Notes and the Incident Report failed to provide a rationale for the medical necessity to restrain the resident on July 1, 2017, and July 8, 2017.” A staff member was interviewed on the morning of July 14, 2017, and acknowledged that the Certified Nursing Assistants “were told to hold the resident down on July 1, 2017, and July 8, 2017, while nurses attempted to reinsert the resident’s [cannula device].”

  • Failure to Tell the Resident, the Resident’s Doctor or a Family Member of a Change in the Resident’s Situation Including a Decline in Health or Injury

    In a summary statement of deficiencies dated August 11, 2017, the state investigator determined that “a physician was not notified for capillary blood glucose [that was] outside the prescribed parameters.” This failure involved one resident at the facility that “placed residents at risk for unmet insulin medication needs.

    A review of the resident’s July 2017 Insolent Administration Records revealed that the resident had “capillary blood glucose [levels] checks prior [that] were 166 and 229 and the two capillary blood glucose checks after [that] were 168 and 244 [respectively].” A review of the resident’s “medical record indicated the physician was not contacted.” At approximately noon on August 7, 2017, a visiting staff member “acknowledged [that] the physician was not notified” as required by state and federal laws.

  • Failure to Hire Individuals without a History of Abusing, Neglecting or Mistreating Residents

    In a summary statement of deficiencies dated August 11, 2017, the State surveyor noted that the facility had “failed to immediately report an allegation of abuse, thoroughly investigate an allegation of abuse, actively prevent further abuse while an allegation of abuse was investigated, and operationalize policies and procedures related to physical abuse.” This deficiency affected seven residents “reviewed for abuse, skin conditions and accidents. This [failure] placed residents at risk for abuse.”

    One incident involved a resident admitted to the facility in 2017. On August 1, 2017, at 11:28 AM, the resident stated that a Certified Nursing Assistant “hit [them] in the genitals. A resident stated [they] told the facility administrator now [the alleged abusive employee] is not allowed in the resident’s room.” However, the state investigator noted that after reviewing the resident’s Progress Notes that there was “no documentation of the incident.”

    The facility’s July 14, 2017, Incident Investigation indicated that the resident reported the staff member “was checking the resident’s brief than hit [them] in the genitals. The resident complained of pain which radiated into the abdomen. The Incident Report indicated there was no abuse or neglect. The report did not include an analysis of the evidence regarding the allegation of abuse or any rationale to justify a conclusion of no abuse or neglect had occurred.”

    The state investigator reminded the facility that they failed to follow their own November 2016 (Oregon Rev.) Policy and Procedure for Abuse, under Screening, Training, Identification, Investigation, Reporting, and Protection that reads in part:

    “It is the facility’s policy to investigate all allegations of abuse and reported allegations to the appropriate reporting authority.”

    “The facility uses the Incident Accident Investigation policy and procedure to investigate concerns and incidents.”

    “Allegation of abuse, neglect or exploitation would be reported immediately to the appropriate State Survey Agency in a timely manner after initial reporting.”

    “Administrative personnel are to immediately remove a staff member involved in the incident from their duties in the staff was to be sent home until administrative personnel completed a thorough investigation of the reporting incident.”

In Need of an Oregon Nursing Home Abuse Attorney?

If you have suffered an injury or were neglected, abused or mistreated at a nursing facility, you have the legal right to seek financial compensation for your damages. Consider hiring a personal injury attorney who specializes in abuse and mistreatment cases. A lawyer working on your behalf can ensure all the paperwork and documentation is submitted promptly to the appropriate courthouse before the statute of limitations expires.

All personal injury cases involving abuse and neglect are handled through contingency fee arrangements. This agreement means you will receive immediate legal representation without the need of making an upfront payment. All your legal fees will be paid only after the case is resolved successfully.


For information on laws and regulations related to Oregon nursing homes, look here.

If you believe that your loved one was neglected or abused at a nursing facility, contact our office for a free case review.

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