Cycle 1
Health 2025-06-27 · Fire 2025-06-27
10 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cottage Grove, OR
Cottage Grove Post Acute
3-star overall rating with 3-star inspections with $20,670 in total fines with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
515 Grant Street, Cottage Grove, OR
(541) 942-5528
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
65
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1982-06-22
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
0.21
Registered nurse staffing · state 0.68 · national 0.68
LPN hours / resident day
1.05
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.98
Nurse aide staffing · state 3.37 · national 2.35
Total nurse hours
4.25
All reported nurse hours · state 4.95 · national 3.89
Licensed hours
1.26
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.85
Weekend nurse staffing · state 4.39 · national 3.43
Weekend RN hours
0.18
Weekend registered nurse coverage · state 0.44 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.22
CMS adjusted RN staffing hours
Adjusted total hours
4.39
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
86%
Annual RN turnover · state 53% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,889
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.24
Composite VBP score used to determine payment impact.
Payment multiplier
0.9952
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.22
Performance 20.87% · Measure score 1.22 · Achievement 1.22 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
5.94
Performance 6.06% · Measure score 5.94 · Achievement 5.94 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
2.06
Baseline 46.88% · Performance 55.26% · Measure score 2.06 · Achievement 2.06 · Improvement 0
Adjusted total nurse staffing
7.68
Baseline 5.60 hours · Performance 5.26 hours · Measure score 7.68 · Achievement 7.68 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.51% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 42 · Observed rate 4.76% · Lower 95% interval 6.16% |
| Discharge to community | 52.31% |
50.57%
1.7 pts better
|
No Different than the National Rate · Eligible stays 44 · Observed rate 45.45% · Lower 95% interval 36.81% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 94.74% |
95.27%
0.5 pts worse
|
Numerator 36 · Denominator 38 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 38 |
| Discharge self-care score | 33.33% |
53.69%
20.4 pts worse
|
Numerator 7 · Denominator 21 |
| Discharge mobility score | 28.57% |
50.94%
22.4 pts worse
|
Numerator 6 · Denominator 21 |
| Pressure ulcers or injuries, new or worsened | 7.89% |
2.29%
5.6 pts worse
|
Numerator 3 · Denominator 38 · Adjusted rate 8.2% |
| Healthcare-associated infections requiring hospitalization | 6.06% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 28 · Observed rate 0% · Lower 95% interval 3.32% |
| Staff COVID-19 vaccination coverage | 1.9% |
8.2%
6.3 pts worse
|
Numerator 2 · Denominator 105 |
| Staff flu vaccination coverage | 25.89% |
42%
16.1 pts worse
|
Numerator 29 · Denominator 112 |
| Discharge function score | 52.38% |
56.45%
4.1 pts worse
|
Numerator 11 · Denominator 21 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 17 · 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 | 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 | 100.0% |
95.2%
4.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
2.4%
0.5 pts worse
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.5% · Q3 2.3% · Q4 5.8% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 19.3% |
4.7%
14.6 pts worse
|
11.4%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 15.6% · Q3 27.8% · Q4 25.6% · 4Q avg 19.3% |
| 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 0.0% · Q2 0.0% · Q3 0.0% · Q4 6.2% · 4Q avg 1.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.7% |
12.5%
2.2 pts worse
|
19.6%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 11.4% · Q3 17.1% · Q4 14.3% · 4Q avg 14.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.6% |
14.7%
3.1 pts better
|
16.7%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 16.7% · Q4 21.6% · 4Q avg 11.6% · 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 | 5.5% |
24.1%
18.6 pts better
|
16.3%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.2% |
15.8%
5.6 pts better
|
14.9%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 6.1% · Q3 2.5% · Q4 8.9% · 4Q avg 10.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
1.7%
1.1 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
2.0%
1.4 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.6% |
22.2%
2.6 pts better
|
19.8%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 27.8% · Q2 33.4% · Q3 10.5% · Q4 10.6% · 4Q avg 19.6% |
| 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 4.4% · Q2 10.6% · Q3 5.1% · Q4 6.4% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
85.4%
12.5 pts better
|
81.7%
16.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.4% · Q2 97.9% · Q3 97.9% · Q4 99.0% · 4Q avg 97.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.5% |
15.1%
4.6 pts better
|
12.0%
1.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.5% · Observed 11.1% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
1.7%
0.4 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 4.3% · Q3 2.0% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.6% |
81.2%
8.4 pts better
|
79.7%
9.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.9% |
21.6%
5.3 pts worse
|
23.9%
3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.9% · Observed 25.9% · Expected 22.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-08 · Fire 2024-03-08
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-11-18 · Fire 2022-11-18
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-06-27
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-07-21
F · Potential for more than minimal harm
2024-03-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-03-08
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 2024-04-01
D · Potential for more than minimal harm
2024-03-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-03-08
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-04-01
Inspection history
Recent health citations
G · Actual harm
2025-06-27
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-07-23
E · Potential for more than minimal harm
2025-06-27
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-07-23
E · Potential for more than minimal harm
2025-06-27
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-07-23
E · Potential for more than minimal harm
2025-06-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-23
D · Potential for more than minimal harm
2025-06-27
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-07-23
D · Potential for more than minimal harm
2025-06-27
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 2025-07-22
D · Potential for more than minimal harm
2025-06-27
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-07-23
D · Potential for more than minimal harm
2025-06-27
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-07-23
D · Potential for more than minimal harm
2025-06-27
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-07-23
D · Potential for more than minimal harm
2025-06-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-23
D · Potential for more than minimal harm
2024-10-16
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-10-02
D · Potential for more than minimal harm
2024-10-16
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 2024-10-02
F · Potential for more than minimal harm
2024-03-08
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-04-01
E · Potential for more than minimal harm
2024-03-08
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-03-08
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-03-08
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 2024-04-01
D · Potential for more than minimal harm
2024-03-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-03-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-01
G · Actual harm
2022-11-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-12-29
E · Potential for more than minimal harm
2022-11-18
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 2022-12-29
E · Potential for more than minimal harm
2022-11-18
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 2022-12-29
E · Potential for more than minimal harm
2022-11-18
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-12-29
E · Potential for more than minimal harm
2022-11-18
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 2022-12-29
E · Potential for more than minimal harm
2022-11-18
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-12-29
D · Potential for more than minimal harm
2022-11-18
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 2022-12-29
D · Potential for more than minimal harm
2022-11-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-12-29
Penalties and ownership
What sits behind the stars
$20,670
2025-06-27
Fine
Fine · fine $20,670
Fine
Ownership
Providence Group Nh, LLC
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Operational/Managerial Control · Individual
Barr, Jennifer
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
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Pompey, Karen
Operational/Managerial Control · Individual
Truist Bank
5% Or Greater Security Interest · Organization
Wallenkampf, Victor
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Creswell Post Acute
Creswell, OR
2-star overall rating with 2-star inspections with 22 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Creekside Health And Rehab Of Cascadia
Eugene, OR
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Cascade Manor
Eugene, OR
3-star overall rating with 4-star inspections with $10,033 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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