Cycle 1
Health 2025-03-28 · Fire 2025-03-28
27 health deficiencies
Top issue: Resident Rights (6 deficiencies)
21 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Newberg, OR
Chehalem Post Acute
1-star overall rating with 1-star inspections with $54,581 in total fines with 27 recent health deficiencies with 21 fire-safety deficiencies in the latest cycle
1900 E. Fulton Street, Newberg, OR
(503) 538-2108
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
Facility snapshot
Beds
84
Certified beds
Average residents
65
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1989-05-19
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
Hours and turnover
RN hours / resident day
0.46
Registered nurse staffing · state 0.68 · national 0.68
LPN hours / resident day
0.97
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
3.48
Nurse aide staffing · state 3.37 · national 2.35
Total nurse hours
4.92
All reported nurse hours · state 4.95 · national 3.89
Licensed hours
1.44
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
4.44
Weekend nurse staffing · state 4.39 · national 3.43
Weekend RN hours
0.40
Weekend registered nurse coverage · state 0.44 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
5.44
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
5,766
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.10
Composite VBP score used to determine payment impact.
Payment multiplier
0.9889
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 22.40% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
1.88
Performance 7.27% · Measure score 1.88 · Achievement 1.88 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
8.65
Baseline 5.6 hours · Performance 5.54 hours · Measure score 8.65 · Achievement 8.65 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.59% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 49 · Observed rate 10.2% · Lower 95% interval 6.62% |
| Discharge to community | 57.29% |
50.57%
6.7 pts better
|
No Different than the National Rate · Eligible stays 51 · Observed rate 49.02% · Lower 95% interval 45.97% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 90.48% |
95.27%
4.8 pts worse
|
Numerator 19 · Denominator 21 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 21 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 4.76% |
2.29%
2.5 pts worse
|
Numerator 1 · Denominator 21 · Adjusted rate 4.02% |
| Healthcare-associated infections requiring hospitalization | 7.27% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 27 · Observed rate 7.41% · Lower 95% interval 4.08% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 92 |
| Staff flu vaccination coverage | 10.96% |
42%
31 pts worse
|
Numerator 24 · Denominator 219 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.9% |
95.5%
2.6 pts worse
|
93.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 89.8% · Q2 84.3% · Q3 100.0% · Q4 97.9% · 4Q avg 92.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.3% |
95.2%
1.9 pts worse
|
95.5%
2.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.6% |
2.4%
2.2 pts worse
|
3.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 5.9% · Q3 6.1% · Q4 2.1% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.3% |
4.7%
6.6 pts worse
|
11.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 22.2% · Q3 9.8% · Q4 0.0% · 4Q avg 11.3% |
| Percentage of long-stay residents who lose too much weight | 1.9% |
5.0%
3.1 pts better
|
5.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 2.5% · Q4 2.6% · 4Q avg 1.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.3% |
12.5%
1.2 pts better
|
19.6%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 12.5% · Q3 12.5% · Q4 13.2% · 4Q avg 11.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.7% |
14.7%
6 pts worse
|
16.7%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 21.4% · Q3 14.8% · Q4 20.0% · 4Q avg 20.7% · 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 | 18.3% |
24.1%
5.8 pts better
|
16.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 21.0% · 4Q avg 18.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.6% |
15.8%
2.2 pts better
|
14.9%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 17.5% · Q3 5.1% · Q4 17.1% · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.7% |
1.7%
3 pts worse
|
1.0%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 5.5% · Q3 7.3% · Q4 1.8% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
2.0%
1.5 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.5% |
22.2%
1.7 pts better
|
19.8%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 23.6% · Q3 23.6% · Q4 26.2% · 4Q avg 20.5% |
| Percentage of long-stay residents with pressure ulcers | 5.5% |
6.5%
1 pts better
|
5.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 4.5% · Q3 8.9% · Q4 4.1% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 55.6% |
85.4%
29.8 pts worse
|
81.7%
26.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 62.2% · Q2 59.2% · Q3 54.2% · Q4 50.4% · 4Q avg 55.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.6% |
15.1%
6.5 pts better
|
12.0%
3.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.6% · Observed 9.1% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.2% |
1.7%
3.5 pts worse
|
1.6%
3.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 5.9% · Q3 6.9% · Q4 3.0% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 51.3% |
81.2%
29.9 pts worse
|
79.7%
28.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 51.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.2% |
21.6%
3.6 pts worse
|
23.9%
1.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.2% · Observed 27.3% · Expected 25.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-04 · Fire 2023-12-04
24 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2022-10-21 · Fire 2022-10-21
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-28
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-04-29
F · Potential for more than minimal harm
2025-03-28
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2025-04-29
F · Potential for more than minimal harm
2025-03-28
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-04-29
F · Potential for more than minimal harm
2025-03-28
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2025-04-29
F · Potential for more than minimal harm
2025-03-28
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-04-29
F · Potential for more than minimal harm
2025-03-28
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-04-29
F · Potential for more than minimal harm
2025-03-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-29
F · Potential for more than minimal harm
2025-03-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-29
F · Potential for more than minimal harm
2025-03-28
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-04-29
F · Potential for more than minimal harm
2025-03-28
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-04-29
F · Potential for more than minimal harm
2025-03-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-29
F · Potential for more than minimal harm
2025-03-28
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-04-29
F · Potential for more than minimal harm
2025-03-28
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-04-29
F · Potential for more than minimal harm
2025-03-28
K791 · Miscellaneous Deficiencies
Fire Safety
Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency.
Corrected 2025-04-29
F · Potential for more than minimal harm
2025-03-28
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-04-29
F · Potential for more than minimal harm
2025-03-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-29
D · Potential for more than minimal harm
2025-03-28
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-04-29
D · Potential for more than minimal harm
2025-03-28
K223 · Egress Deficiencies
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 2025-04-29
D · Potential for more than minimal harm
2025-03-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-29
D · Potential for more than minimal harm
2025-03-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-04-29
D · Potential for more than minimal harm
2025-03-28
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-04-29
F · Potential for more than minimal harm
2023-12-04
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-01-19
F · Potential for more than minimal harm
2023-12-04
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2024-01-23
F · Potential for more than minimal harm
2023-12-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-01-19
F · Potential for more than minimal harm
2023-12-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-23
F · Potential for more than minimal harm
2023-12-04
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-01-23
F · Potential for more than minimal harm
2023-12-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-01-23
E · Potential for more than minimal harm
2023-12-04
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-12-04
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-12-04
K223 · Egress Deficiencies
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 2024-01-19
D · Potential for more than minimal harm
2023-12-04
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-12-04
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-04
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-04
K932 · Smoke Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-01-23
F · Potential for more than minimal harm
2022-10-21
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-11-15
E · Potential for more than minimal harm
2022-10-21
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-11-15
D · Potential for more than minimal harm
2022-10-21
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-11-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-15
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2026-02-03
D · Potential for more than minimal harm
2026-01-15
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 2026-02-03
E · Potential for more than minimal harm
2025-08-13
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-08-26
F · Potential for more than minimal harm
2025-03-28
F727 · Nursing and Physician Services Deficiencies
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 2025-04-29
F · Potential for more than minimal harm
2025-03-28
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-04-29
F · Potential for more than minimal harm
2025-03-28
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-04-29
F · Potential for more than minimal harm
2025-03-28
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2025-04-29
E · Potential for more than minimal harm
2025-03-28
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-04-29
E · Potential for more than minimal harm
2025-03-28
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-04-29
E · Potential for more than minimal harm
2025-03-28
F725 · Nursing and Physician Services Deficiencies
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 2025-04-29
E · Potential for more than minimal harm
2025-03-28
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-04-29
E · Potential for more than minimal harm
2025-03-28
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-04-29
E · Potential for more than minimal harm
2025-03-28
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 2025-04-29
E · Potential for more than minimal harm
2025-03-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-29
D · Potential for more than minimal harm
2025-03-28
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-04-29
D · Potential for more than minimal harm
2025-03-28
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 2025-04-29
D · Potential for more than minimal harm
2025-03-28
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-29
D · Potential for more than minimal harm
2025-03-28
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-29
D · Potential for more than minimal harm
2025-03-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-29
D · Potential for more than minimal harm
2025-03-28
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 2025-04-29
D · Potential for more than minimal harm
2025-03-28
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-04-29
D · Potential for more than minimal harm
2025-03-28
F776 · Administration Deficiencies
Health
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Corrected 2025-04-29
D · Potential for more than minimal harm
2025-03-28
F777 · Administration Deficiencies
Health
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Corrected 2025-04-29
D · Potential for more than minimal harm
2025-03-28
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-04-29
D · Potential for more than minimal harm
2025-03-28
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-04-29
C · Minimal harm
2025-03-28
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-04-29
B · Minimal harm
2025-03-28
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 2025-04-29
G · Actual harm
2025-01-07
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-01-30
D · Potential for more than minimal harm
2025-01-07
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2025-01-30
D · Potential for more than minimal harm
2025-01-07
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 2025-01-30
D · Potential for more than minimal harm
2024-09-19
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-10-07
J · Immediate jeopardy
2023-12-04
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 2024-01-23
E · Potential for more than minimal harm
2023-12-04
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-01-23
E · Potential for more than minimal harm
2023-12-04
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 2024-01-23
E · Potential for more than minimal harm
2023-12-04
F725 · Nursing and Physician Services Deficiencies
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 2024-01-23
E · Potential for more than minimal harm
2023-12-04
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-01-23
E · Potential for more than minimal harm
2023-12-04
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 2024-01-23
E · Potential for more than minimal harm
2023-12-04
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 2024-01-23
E · Potential for more than minimal harm
2023-12-04
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 2024-01-23
D · Potential for more than minimal harm
2023-12-04
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-04
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-04
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-04
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-04
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-04
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-04
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-04
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-04
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-04
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-04
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 2024-01-23
G · Actual harm
2022-10-21
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 2022-11-15
F · Potential for more than minimal harm
2022-10-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-15
E · Potential for more than minimal harm
2022-10-21
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 2022-11-15
D · Potential for more than minimal harm
2022-10-21
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-11-15
D · Potential for more than minimal harm
2022-10-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-11-15
D · Potential for more than minimal harm
2022-10-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-11-15
D · Potential for more than minimal harm
2022-10-21
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2022-11-15
Penalties and ownership
What sits behind the stars
$14,788
2025-01-07
Fine
Fine · fine $14,788
Fine
$39,793
2023-12-04
Fine
Fine · fine $39,793
Fine
Ownership
Providence Group Nh, LLC
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Operational/Managerial Control · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Jergensen, Joshua
Operational/Managerial Control · Individual
Mitchell, John
Operational/Managerial Control · Individual
Morris, Christopher
Operational/Managerial Control · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Nyssen, Sara
Operational/Managerial Control · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Park, Trevor
Operational/Managerial Control · Individual
Truist Bank
5% Or Greater Security Interest · Organization
Nearby options
Other facilities in reach
#1
Marquis Newberg
Newberg, OR
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Marquis Wilsonville Post Acute Rehab
Wilsonville, OR
5-star overall rating with 5-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Avamere Rehabilitation Of King City
Tigard, OR
4-star overall rating with 3-star inspections with $49,348 in total fines with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
Jump out