Cycle 1
Health 2025-01-21 · Fire 2025-01-21
14 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Hillsboro, OR
Avamere Rehabilitation Of Hillsboro
2-star overall rating with 2-star inspections with $23,465 in total fines with 14 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
650 Se Oak Street, Hillsboro, OR
(503) 648-8588
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
87
Certified beds
Average residents
76
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avamere
Operator or chain grouping
Approved since
1996-04-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
33 facilities
Chain averages 3 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.61
Registered nurse staffing · state 0.68 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
3.00
Nurse aide staffing · state 3.37 · national 2.35
Total nurse hours
4.55
All reported nurse hours · state 4.95 · national 3.89
Licensed hours
1.55
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.95
Weekend nurse staffing · state 4.39 · national 3.43
Weekend RN hours
0.53
Weekend registered nurse coverage · state 0.44 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.64
CMS adjusted RN staffing hours
Adjusted total hours
4.76
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 53% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,352
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.19
Composite VBP score used to determine payment impact.
Payment multiplier
0.9876
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.34% · Performance 24.32% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.96
Baseline 6.06% · Performance 7.25% · Measure score 1.96 · Achievement 1.96 · Improvement 0
Total nurse turnover
5.52
Baseline 47.48% · Performance 41.11% · Measure score 5.52 · Achievement 5.52 · Improvement 2.31
Adjusted total nurse staffing
5.80
Baseline 4.59 hours · Performance 4.73 hours · Measure score 5.80 · Achievement 5.80 · Improvement 0.65
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.51% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 152 · Observed rate 11.18% · Lower 95% interval 7.97% |
| Discharge to community | 60.12% |
50.57%
9.5 pts better
|
Better than the National Rate · Eligible stays 153 · Observed rate 60.13% · Lower 95% interval 52.84% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 98.9% |
95.27%
3.6 pts better
|
Numerator 90 · Denominator 91 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 91 |
| Discharge self-care score | 41.67% |
53.69%
12 pts worse
|
Numerator 25 · Denominator 60 |
| Discharge mobility score | 41.67% |
50.94%
9.3 pts worse
|
Numerator 25 · Denominator 60 |
| Pressure ulcers or injuries, new or worsened | 3.3% |
2.29%
1 pts worse
|
Numerator 3 · Denominator 91 · Adjusted rate 3.09% |
| Healthcare-associated infections requiring hospitalization | 7.25% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 97 · Observed rate 6.19% · Lower 95% interval 3.99% |
| Staff COVID-19 vaccination coverage | 14.29% |
8.2%
6.1 pts better
|
Numerator 18 · Denominator 126 |
| Staff flu vaccination coverage | 55.19% |
42%
13.2 pts better
|
Numerator 85 · Denominator 154 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 30 · Denominator 60 |
| Transfer of health information to provider | 80% |
95.95%
16 pts worse
|
Numerator 16 · Denominator 20 |
| Transfer of health information to patient | 30.16% |
96.28%
66.1 pts worse
|
Numerator 19 · Denominator 63 |
| Resident COVID-19 vaccinations up to date | 57.45% |
25.2%
32.2 pts better
|
Numerator 27 · Denominator 47 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.5%
4.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.3% |
95.2%
2.1 pts better
|
95.5%
1.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.2% |
2.4%
0.2 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 2.9% · Q4 2.7% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.6% |
4.7%
2.1 pts better
|
11.4%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.6% · Q4 6.7% · 4Q avg 2.6% |
| Percentage of long-stay residents who lose too much weight | 5.5% |
5.0%
0.5 pts worse
|
5.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 3.1% · Q3 3.2% · Q4 2.9% · 4Q avg 5.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 3.1% |
12.5%
9.4 pts better
|
19.6%
16.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.1% · Q3 0.0% · Q4 5.7% · 4Q avg 3.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 1.9% |
14.7%
12.8 pts better
|
16.7%
14.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 6.7% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.7% |
0.1%
0.6 pts worse
|
0.1%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.7% · 4Q avg 0.7% |
| Percentage of long-stay residents whose ability to walk independently worsened | 31.3% |
24.1%
7.2 pts worse
|
16.3%
15 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 31.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.9% |
15.8%
0.1 pts worse
|
14.9%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 6.2% · Q3 22.6% · Q4 17.6% · 4Q avg 15.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
1.7%
1.3 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.5% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.9% |
2.0%
0.9 pts worse
|
1.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 2.9% · Q4 5.4% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.9% |
22.2%
7.7 pts worse
|
19.8%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.3% · Q2 27.0% · Q3 25.8% · Q4 27.3% · 4Q avg 29.9% |
| Percentage of long-stay residents with pressure ulcers | 6.6% |
6.5%
0.1 pts worse
|
5.1%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 6.0% · Q3 2.5% · Q4 6.5% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
85.4%
14.1 pts better
|
81.7%
17.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.2% · Q2 99.7% · Q3 100.0% · Q4 99.0% · 4Q avg 99.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.9% |
15.1%
0.8 pts worse
|
12.0%
3.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.9% · Observed 14.9% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.7%
0.9 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.5% · Q3 0.5% · Q4 0.5% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.4% |
81.2%
17.2 pts better
|
79.7%
18.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.8% |
21.6%
7.2 pts worse
|
23.9%
4.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.8% · Observed 28.4% · Expected 23.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-31 · Fire 2023-07-31
13 health deficiencies
Top issue: Resident Rights (4 deficiencies)
4 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2019-07-15 · Fire 2019-07-15
5 health deficiencies
Top issue: Resident Rights (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-21
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-01-21
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-01-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-10
F · Potential for more than minimal harm
2023-07-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-25
F · Potential for more than minimal harm
2023-07-31
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-07-31
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-07-31
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-08-25
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-02-03
G · Actual harm
2025-05-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-16
E · Potential for more than minimal harm
2025-01-21
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-02-25
E · Potential for more than minimal harm
2025-01-21
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-02-25
D · Potential for more than minimal harm
2025-01-21
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-02-25
D · Potential for more than minimal harm
2025-01-21
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-02-25
D · Potential for more than minimal harm
2025-01-21
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-02-25
D · Potential for more than minimal harm
2025-01-21
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-02-25
D · Potential for more than minimal harm
2025-01-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-25
D · Potential for more than minimal harm
2025-01-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-25
D · Potential for more than minimal harm
2025-01-21
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-02-25
D · Potential for more than minimal harm
2025-01-21
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-02-25
D · Potential for more than minimal harm
2025-01-21
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2025-02-25
C · Minimal harm
2025-01-21
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-02-25
D · Potential for more than minimal harm
2024-11-07
F560 · Resident Rights Deficiencies
Health
Protect a residents' right to refuse some types of non-requested transfers within the nursing home.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-09-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-08
G · Actual harm
2023-07-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-07-31
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-07-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-31
D · Potential for more than minimal harm
2023-07-31
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-08-31
D · Potential for more than minimal harm
2023-07-31
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2023-08-31
D · Potential for more than minimal harm
2023-07-31
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-08-31
D · Potential for more than minimal harm
2023-07-31
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-08-31
D · Potential for more than minimal harm
2023-07-31
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2021-07-10
D · Potential for more than minimal harm
2023-07-31
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-08-31
D · Potential for more than minimal harm
2023-07-31
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-08-31
D · Potential for more than minimal harm
2023-07-31
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2023-08-31
D · Potential for more than minimal harm
2019-07-15
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2019-08-16
D · Potential for more than minimal harm
2019-07-15
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2019-08-16
D · Potential for more than minimal harm
2019-07-15
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2019-08-16
D · Potential for more than minimal harm
2019-07-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-08-16
C · Minimal harm
2019-07-15
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2019-08-16
Penalties and ownership
What sits behind the stars
$23,465
2023-07-31
Fine
Fine · fine $23,465
Fine
Ownership
Miller, Karl
5% Or Greater Direct Ownership Interest · Individual
Avamere Skilled Advisors LLC
Operational/Managerial Control · Organization
Kofstad, Mary
Corporate Officer · Individual
Loveday, Raven
W-2 Managing Employee · Individual
Morris, Christopher
Contracted Managing Employee · Individual
Simpson, Andrew
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Hillsboro Health & Rehabilitation Center
Hillsboro, OR
4-star overall rating with 4-star inspections with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Forest Grove Post Acute
Forest Grove, OR
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Marquis Forest Grove Post Acute Rehab
Forest Grove, OR
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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