Blue Mountain Care Center: Transfer Safety Failure - OR
The incident at Blue Mountain Care Center, a nursing facility at 112 East Fifth Street in Prairie City, came to light during a complaint inspection completed May 28, 2026. Federal inspectors found the facility failed to follow a care plan for transfers for the resident, identified in inspection records as Resident 4.
Resident 4 had been admitted to the facility in 2026 with a hip fracture. Her care plan, in place since April 13, required that she be transferred using a sit-to-stand mechanical lift device for every transfer. The care plan was unambiguous: she was not to be moved any other way.
The nurse, identified in records as Staff 5, an LPN, told inspectors on May 27 that he had offered to help the resident get to lunch. He gave her what he described as a bear hug and had her stand and pivot on her own from the recliner to the wheelchair. He said he assumed she was a one-person assist because he had seen her working with one person during therapy sessions and because she appeared capable of standing on her own. He said he was not aware she required the mechanical lift.
The resident described it differently. She told inspectors Staff 5 grabbed her, she put her hands on his shoulders, and he transferred her. She said she was not used to being transferred that way. She also said he did not ask what her transfer status was before he did it.
No injury occurred. But the resident had already reported the same nurse for a similar transfer weeks earlier. On May 12, an occupational therapist emailed the facility's registered nurse care manager to flag that Resident 4 had reported Staff 5 transferred her from the recliner to the wheelchair without the mechanical lift. That email stated explicitly that the resident was not to be transferred any other way than by using the device. By May 27, the occupational therapist told inspectors the resident had reported it happening again, this time by stand pivot instead of the required equipment.
When inspectors interviewed Staff 5 directly, he acknowledged he did not follow Resident 4's care plan. He said that if the care plan indicated the resident required the device, it should have been followed.
That acknowledgment came the day before the inspection closed. On May 28, the facility's Director of Nursing and the registered nurse care manager both confirmed to inspectors that Staff 5 had not followed the care plan.
The inspection rated the deficiency as minimal harm or potential for actual harm, affecting a small number of residents. Inspectors reviewed four residents' transfer records in total and found the failure in one case.
What the record shows is a nurse who bypassed a care plan requirement twice for the same resident, the second time after the facility had already been notified in writing that it had happened once. A resident recovering from a broken hip was transferred without the equipment designed to protect her, by a staff member who decided, without looking at her chart, that she probably didn't need it.
She put her hands on his shoulders and let him move her. She said she wasn't used to being transferred that way.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Blue Mountain Care Center from 2026-05-28 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 21, 2026 · Our methodology
BLUE MOUNTAIN CARE CENTER in PRAIRIE CITY, OR was cited for violations during a health inspection on May 28, 2026.
Federal inspectors found the facility failed to follow a care plan for transfers for the resident, identified in inspection records as Resident 4.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.