19 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Portland, OR
1-star overall rating with 1-star inspections with $185,923 in total fines with 19 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
5601 Se 122nd Avenue, Portland, OR
(503) 761-3181
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
105
Certified beds
Average residents
80
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1988-07-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 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
RN hours / resident day
0.52
Registered nurse staffing · state 0.68 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
3.43
Nurse aide staffing · state 3.37 · national 2.35
Total nurse hours
4.81
All reported nurse hours · state 4.95 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
4.23
Weekend nurse staffing · state 4.39 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.44 · national 0.47
Physical therapist
0.20
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.55
CMS adjusted RN staffing hours
Adjusted total hours
5.13
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 53% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Program rank
2,094
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
51.84
Composite VBP score used to determine payment impact.
Payment multiplier
1.0063
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
7.25
Baseline 19.54% · Performance 18.07% · Measure score 7.25 · Achievement 7.25 · Improvement 5.33
Healthcare-associated infections
3.20
Baseline 6.79% · Performance 6.88% · Measure score 3.20 · Achievement 3.20 · Improvement 0
Total nurse turnover
2.60
Baseline 40.24% · Performance 53.06% · Measure score 2.60 · Achievement 2.60 · Improvement 0
Adjusted total nurse staffing
7.69
Baseline 5.35 hours · Performance 5.27 hours · Measure score 7.69 · Achievement 7.69 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.74% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 55 · Observed rate 7.27% · Lower 95% interval 6.33% |
| Discharge to community | 59.55% |
50.57%
9 pts better
|
No Different than the National Rate · Eligible stays 60 · Observed rate 51.67% · Lower 95% interval 44.06% |
| Medicare spending per beneficiary | 0.72 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 98.55% |
95.27%
3.3 pts better
|
Numerator 68 · Denominator 69 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 69 |
| Discharge self-care score | 48.84% |
53.69%
4.8 pts worse
|
Numerator 21 · Denominator 43 |
| Discharge mobility score | 60.47% |
50.94%
9.5 pts better
|
Numerator 26 · Denominator 43 |
| Pressure ulcers or injuries, new or worsened | 2.9% |
2.29%
0.6 pts worse
|
Numerator 2 · Denominator 69 · Adjusted rate 2.69% |
| Healthcare-associated infections requiring hospitalization | 6.88% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 44 · Observed rate 6.82% · Lower 95% interval 4.16% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 105 |
| Staff flu vaccination coverage | 22.29% |
42%
19.7 pts worse
|
Numerator 37 · Denominator 166 |
| Discharge function score | 55.81% |
56.45%
0.6 pts worse
|
Numerator 24 · Denominator 43 |
| Transfer of health information to provider | 91.89% |
95.95%
4.1 pts worse
|
Numerator 34 · Denominator 37 |
| Transfer of health information to patient | 84% |
96.28%
12.3 pts worse
|
Numerator 21 · Denominator 25 |
| Resident COVID-19 vaccinations up to date | 41.18% |
25.2%
16 pts better
|
Numerator 14 · Denominator 34 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
95.5%
3.5 pts better
|
93.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.8% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.2% |
95.2%
3 pts better
|
95.5%
2.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.5% |
2.4%
1.9 pts better
|
3.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.5% |
4.7%
1.8 pts worse
|
11.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 7.1% · Q3 6.8% · Q4 7.0% · 4Q avg 6.5% |
| Percentage of long-stay residents who lose too much weight | 0.6% |
5.0%
4.4 pts better
|
5.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.7% |
12.5%
1.8 pts better
|
19.6%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 7.7% · Q3 7.3% · Q4 15.8% · 4Q avg 10.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.8% |
14.7%
0.9 pts better
|
16.7%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 9.4% · Q3 15.2% · Q4 15.9% · 4Q avg 13.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.7% |
24.1%
2.4 pts better
|
16.3%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.2% |
15.8%
6.6 pts better
|
14.9%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 7.7% · Q3 0.0% · Q4 14.3% · 4Q avg 9.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
1.7%
0.8 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.8% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.9% |
2.0%
0.1 pts better
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.0% · Q3 0.0% · Q4 3.1% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.0% |
22.2%
2.2 pts better
|
19.8%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.4% · Q2 30.9% · Q3 21.6% · Q4 14.5% · 4Q avg 20.0% |
| Percentage of long-stay residents with pressure ulcers | 6.9% |
6.5%
0.4 pts worse
|
5.1%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 5.2% · Q3 5.9% · Q4 9.2% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.2% |
85.4%
9.8 pts better
|
81.7%
13.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.9% · Q2 95.8% · Q3 95.1% · Q4 96.0% · 4Q avg 95.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.9% |
15.1%
7.2 pts better
|
12.0%
4.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.9% · Observed 8.9% · Expected 12.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.2% |
1.7%
2.5 pts worse
|
1.6%
2.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 4.9% · Q3 3.0% · Q4 3.3% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.1% |
81.2%
8.9 pts better
|
79.7%
10.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.9% |
21.6%
11.3 pts worse
|
23.9%
9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.9% · Observed 37.8% · Expected 27.3% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (6 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Nursing and Physician Services (1 deficiency)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-05-29
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-29
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-29
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-05-29
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-05-29
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2024-02-16
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-28
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-06
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-16
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-18
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-18
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-01-18
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-01-18
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-01-18
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-01-18
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-01-18
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-01-18
Fire Safety
Meet other general requirements.
Corrected 2023-01-18
Inspection history
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-14
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Not marked corrected
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-28
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2025-05-29
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2025-05-29
Health
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.
Corrected 2025-05-29
Health
Post nurse staffing information every day.
Corrected 2025-05-29
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 2025-05-29
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2025-05-29
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-05-29
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-05-29
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-05-29
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-05-29
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-29
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-05-29
Health
Provide activities to meet all resident's needs.
Corrected 2025-05-29
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-29
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-05-29
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-05-29
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-02-17
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-17
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-26
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-02-16
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-16
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 2024-02-16
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-03-26
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2024-02-16
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-02-16
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-02-16
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-02-16
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-02-16
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-02-16
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-02-16
Health
Respond appropriately to all alleged violations.
Corrected 2024-02-16
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-02-16
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-02-16
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-16
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-02-16
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-09-30
Health
Post nurse staffing information every day.
Corrected 2023-01-18
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-06-22
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-01-18
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-01-18
Penalties and ownership
Fine · fine $149,783
Fine
Fine · fine $36,140
Fine
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
Nearby options
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5-star overall rating with 4-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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Portland, OR
2-star overall rating with 1-star inspections with $44,133 in total fines with 15 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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