Cycle 1
Health 2025-07-25 · Fire 2025-07-25
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Forest Grove, OR
Forest Grove Post Acute
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
3900 Pacific Avenue, Forest Grove, OR
(503) 359-0449
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
114
Certified beds
Average residents
79
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1983-07-11
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
Hours and turnover
RN hours / resident day
0.39
Registered nurse staffing · state 0.68 · national 0.68
LPN hours / resident day
1.15
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
4.54
All reported nurse hours · state 4.95 · national 3.89
Licensed hours
1.54
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
4.09
Weekend nurse staffing · state 4.39 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.44 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.41
CMS adjusted RN staffing hours
Adjusted total hours
4.87
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 53% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
179
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
79.69
Composite VBP score used to determine payment impact.
Payment multiplier
1.0258
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.52
Baseline 17.60% · Performance 17.48% · Measure score 8.52 · Achievement 8.52 · Improvement 1.53
Healthcare-associated infections
6.47
Baseline 6.01% · Performance 5.90% · Measure score 6.47 · Achievement 6.47 · Improvement 0.58
Total nurse turnover
8.55
Baseline 37.08% · Performance 28.74% · Measure score 8.55 · Achievement 8.55 · Improvement 6.32
Adjusted total nurse staffing
8.33
Baseline 6 hours · Performance 5.45 hours · Measure score 8.33 · Achievement 8.33 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.95% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 170 · Observed rate 8.24% · Lower 95% interval 7.25% |
| Discharge to community | 72.24% |
50.57%
21.7 pts better
|
Better than the National Rate · Eligible stays 177 · Observed rate 69.49% · Lower 95% interval 66.04% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 110 · Denominator 110 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 110 |
| Discharge self-care score | 42.22% |
53.69%
11.5 pts worse
|
Numerator 38 · Denominator 90 |
| Discharge mobility score | 40% |
50.94%
10.9 pts worse
|
Numerator 36 · Denominator 90 |
| Pressure ulcers or injuries, new or worsened | 1.82% |
2.29%
0.5 pts better
|
Numerator 2 · Denominator 110 · Adjusted rate 1.68% |
| Healthcare-associated infections requiring hospitalization | 5.9% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 102 · Observed rate 3.92% · Lower 95% interval 3.71% |
| Staff COVID-19 vaccination coverage | 26.67% |
8.2%
18.5 pts better
|
Numerator 32 · Denominator 120 |
| Staff flu vaccination coverage | 52.46% |
42%
10.5 pts better
|
Numerator 64 · Denominator 122 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 45 · Denominator 90 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 90 · Denominator 90 |
| Resident COVID-19 vaccinations up to date | 42.62% |
25.2%
17.4 pts better
|
Numerator 26 · Denominator 61 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.0% |
95.5%
2.5 pts better
|
93.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.0% · Q2 95.7% · Q3 100.0% · Q4 100.0% · 4Q avg 98.0% |
| 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 | 1.5% |
2.4%
0.9 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.1% · Q3 2.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.6% |
4.7%
4.9 pts worse
|
11.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 8.6% · Q3 7.0% · Q4 13.0% · 4Q avg 9.6% |
| Percentage of long-stay residents who lose too much weight | 6.1% |
5.0%
1.1 pts worse
|
5.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 9.5% · Q3 4.4% · Q4 2.0% · 4Q avg 6.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.5% |
12.5%
3 pts better
|
19.6%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 7.1% · Q3 6.7% · Q4 10.2% · 4Q avg 9.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.6% |
14.7%
2.1 pts better
|
16.7%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 9.1% · Q3 11.4% · Q4 13.9% · 4Q avg 12.6% · 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 | 29.4% |
24.1%
5.3 pts worse
|
16.3%
13.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 29.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.2% |
15.8%
1.6 pts better
|
14.9%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 10.0% · Q3 4.8% · Q4 17.4% · 4Q avg 14.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.3% |
1.7%
1.6 pts worse
|
1.0%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 5.8% · Q3 1.5% · Q4 0.0% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.5% |
2.0%
1.5 pts worse
|
1.7%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 4.3% · Q3 6.0% · Q4 0.0% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.9% |
22.2%
0.7 pts worse
|
19.8%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.1% · Q2 28.4% · Q3 17.5% · Q4 21.4% · 4Q avg 22.9% |
| Percentage of long-stay residents with pressure ulcers | 9.8% |
6.5%
3.3 pts worse
|
5.1%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 3.4% · Q3 5.4% · Q4 15.4% · 4Q avg 9.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.1% |
85.4%
1.7 pts better
|
81.7%
5.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 86.7% · Q2 86.8% · Q3 90.0% · Q4 84.9% · 4Q avg 87.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.8% |
15.1%
7.3 pts better
|
12.0%
4.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.8% · Observed 7.6% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.7%
0.1 pts better
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 3.2% · Q3 2.1% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.1% |
81.2%
6.9 pts better
|
79.7%
8.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.5% |
21.6%
9.1 pts better
|
23.9%
11.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.5% · Observed 12.7% · Expected 24.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-14 · Fire 2024-06-14
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2019-07-16 · Fire 2019-07-16
11 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-25
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 2025-08-27
D · Potential for more than minimal harm
2025-07-25
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-08-27
F · Potential for more than minimal harm
2024-06-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-15
D · Potential for more than minimal harm
2024-06-14
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-07-15
F · Potential for more than minimal harm
2019-07-16
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2019-08-29
F · Potential for more than minimal harm
2019-07-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-08-29
F · Potential for more than minimal harm
2019-07-16
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-08-29
F · Potential for more than minimal harm
2019-07-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-08-29
F · Potential for more than minimal harm
2019-07-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-09-26
E · Potential for more than minimal harm
2019-07-16
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2019-08-29
D · Potential for more than minimal harm
2019-07-16
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2019-08-29
D · Potential for more than minimal harm
2019-07-16
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-08-29
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-25
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-08-27
D · Potential for more than minimal harm
2025-07-25
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 2025-08-27
E · Potential for more than minimal harm
2024-12-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-07
G · Actual harm
2024-06-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-03
F · Potential for more than minimal harm
2024-06-14
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-07-15
E · Potential for more than minimal harm
2024-06-14
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-07-15
E · Potential for more than minimal harm
2024-06-14
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 2024-07-15
D · Potential for more than minimal harm
2024-06-14
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 2024-07-15
D · Potential for more than minimal harm
2024-06-14
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-07-15
D · Potential for more than minimal harm
2024-06-14
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 2024-07-15
D · Potential for more than minimal harm
2023-10-06
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2023-10-18
J · Immediate jeopardy
2019-07-16
F741 · Quality of Life and Care Deficiencies
Health
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Corrected 2018-11-29
G · Actual harm
2019-07-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-08-29
G · Actual harm
2019-07-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-08-29
F · Potential for more than minimal harm
2019-07-16
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 2019-08-29
F · Potential for more than minimal harm
2019-07-16
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2019-08-29
E · Potential for more than minimal harm
2019-07-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-08-29
D · Potential for more than minimal harm
2019-07-16
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 2019-08-29
D · Potential for more than minimal harm
2019-07-16
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 2019-08-29
D · Potential for more than minimal harm
2019-07-16
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2019-08-29
D · Potential for more than minimal harm
2019-07-16
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 2019-08-29
Penalties and ownership
What sits behind the stars
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
Larson, David
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
Roekel, Kayla
Operational/Managerial Control · Individual
Truist Bank
5% Or Greater Security Interest · Organization
Nearby options
Other facilities in reach
#1
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
#2
Avamere Rehabilitation Of Hillsboro
Hillsboro, OR
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
#3
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
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