Cycle 1
Health 2024-11-22 · Fire 2024-11-22
14 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Portland, OR
Glisan Post Acute
2-star overall rating with 2-star inspections with $111,212 in total fines with 14 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
9750 Ne Glisan Street, Portland, OR
(503) 256-3920
Overall
2 / 5
CMS overall stars
Health inspections
2 / 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
100
Certified beds
Average residents
77
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1977-02-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.47
Registered nurse staffing
LPN hours / resident day
0.80
Licensed practical nurse staffing
Aide hours / resident day
3.60
Nurse aide staffing
Weekend hours
4.32
Weekend nurse staffing
RN turnover
80%
Annual RN turnover
Total nurse turnover
57%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
95.5%
4.1 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.4% |
2.4%
About the same
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 1.4% |
4.7%
3.3 pts better
|
11.4%
10 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 0.9% |
5.0%
4.1 pts better
|
5.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.1% |
12.5%
1.6 pts worse
|
19.6%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 14.7% |
14.7%
About the same
|
16.7%
2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 29.8% |
24.1%
5.7 pts worse
|
16.3%
13.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.9% |
15.8%
0.9 pts better
|
14.9%
About the same
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.7%
1.7 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
2.0%
1.6 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.1% |
22.2%
7.1 pts better
|
19.8%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 7.0% |
6.5%
0.5 pts worse
|
5.1%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.0% |
85.4%
6.6 pts better
|
81.7%
10.3 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 27.9% |
15.1%
12.8 pts worse
|
12.0%
15.9 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.5% |
1.7%
0.8 pts worse
|
1.6%
0.9 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.8% |
81.2%
5.6 pts better
|
79.7%
7.1 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 4.0% |
21.6%
17.6 pts better
|
23.9%
19.9 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-11 · Fire 2023-08-11
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-05-25 · Fire 2022-05-25
12 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-11-22
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-11-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-12-27
F · Potential for more than minimal harm
2023-08-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-18
F · Potential for more than minimal harm
2023-08-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-18
E · Potential for more than minimal harm
2023-08-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-08-11
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-08-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-08-11
K932 · Smoke Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-09-18
E · Potential for more than minimal harm
2022-05-25
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-07-07
D · Potential for more than minimal harm
2022-05-25
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2022-07-07
D · Potential for more than minimal harm
2022-05-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-07-07
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-09
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 2025-07-23
D · Potential for more than minimal harm
2025-03-20
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 2025-04-11
E · Potential for more than minimal harm
2024-11-22
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 2024-12-27
D · Potential for more than minimal harm
2024-11-22
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 2024-12-27
D · Potential for more than minimal harm
2024-11-22
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 2024-12-27
D · Potential for more than minimal harm
2024-11-22
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-11-22
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 2024-12-27
D · Potential for more than minimal harm
2024-11-22
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-11-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-11-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-11-22
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-11-22
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-11-22
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 2024-12-27
D · Potential for more than minimal harm
2024-11-22
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 2024-12-27
G · Actual harm
2024-07-24
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 2023-11-16
G · Actual harm
2024-03-27
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 2024-03-22
G · Actual harm
2023-08-11
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 2023-09-18
E · Potential for more than minimal harm
2023-08-11
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 2023-09-18
E · Potential for more than minimal harm
2023-08-11
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 2023-09-18
E · Potential for more than minimal harm
2023-08-11
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 2023-09-18
D · Potential for more than minimal harm
2023-08-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-08-11
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-08-11
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 2023-09-18
D · Potential for more than minimal harm
2023-08-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-18
J · Immediate jeopardy
2023-04-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-25
J · Immediate jeopardy
2023-04-14
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 2023-05-25
F · Potential for more than minimal harm
2023-04-14
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2023-05-25
D · Potential for more than minimal harm
2023-04-14
F573 · Resident Rights Deficiencies
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2023-05-25
D · Potential for more than minimal harm
2023-04-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-05-25
D · Potential for more than minimal harm
2023-04-14
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 2023-05-25
D · Potential for more than minimal harm
2023-04-14
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 2023-05-25
F · Potential for more than minimal harm
2022-05-25
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 2022-07-07
D · Potential for more than minimal harm
2022-05-25
F657 · Resident Assessment and Care Planning Deficiencies
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 2022-07-07
D · Potential for more than minimal harm
2022-05-25
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-07-07
D · Potential for more than minimal harm
2022-05-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-07-07
D · Potential for more than minimal harm
2022-05-25
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 2022-07-07
Penalties and ownership
What sits behind the stars
$13,049
2023-08-11
Fine
Fine · fine $13,049
Fine
$98,163
2023-04-14
Fine
Fine · fine $98,163
Fine
$0
2023-04-14
Payment Denial
Payment Denial · denial start 2023-05-20 · 5 days
5 day denial
Ownership
Providence Group Nh, LLC
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Operational/Managerial Control · Individual
Cano, Pilo
Operational/Managerial Control · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Jergensen, Joshua
Operational/Managerial Control · Individual
Kempfer, Gretchen
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
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Truist Bank
5% Or Greater Security Interest · Organization
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3-star overall rating with 3-star inspections with 11 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
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Portland, OR
4-star overall rating with 3-star inspections with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Marquis Mill Park
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2-star overall rating with 2-star inspections with $17,345 in total fines with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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