Cycle 1
Health 2025-09-05 · Fire 2025-09-05
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Portland, OR
Holladay Park Plaza
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1300 Ne 16th Avenue, Portland, OR
(503) 288-6671
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
51
Certified beds
Average residents
31
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Pacific Retirement Services
Operator or chain grouping
Approved since
1998-08-14
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
10 facilities
Chain averages 5 overall / 4 health / 4 staffing / 5 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
1.12
Registered nurse staffing · state 0.68 · national 0.68
LPN hours / resident day
0.48
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
3.88
Nurse aide staffing · state 3.37 · national 2.35
Total nurse hours
5.48
All reported nurse hours · state 4.95 · national 3.89
Licensed hours
1.60
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
4.92
Weekend nurse staffing · state 4.39 · national 3.43
Weekend RN hours
0.88
Weekend registered nurse coverage · state 0.44 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.12
CMS adjusted RN staffing hours
Adjusted total hours
5.50
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 53% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
583
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
66.96
Composite VBP score used to determine payment impact.
Payment multiplier
1.0207
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.88
Baseline 17.08% · Performance 17.78% · Measure score 7.88 · Achievement 7.88 · Improvement 0
Healthcare-associated infections
8.35
Baseline 5.72% · Performance 5.34% · Measure score 8.35 · Achievement 8.35 · Improvement 4.74
Total nurse turnover
0.56
Baseline 56.92% · Performance 61.40% · Measure score 0.56 · Achievement 0.56 · Improvement 0
Adjusted total nurse staffing
10
Baseline 5.98 hours · Performance 5.81 hours · Measure score 10 · Achievement 10 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.18% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 163 · Observed rate 4.91% · Lower 95% interval 6.04% |
| Discharge to community | 72.38% |
50.57%
21.8 pts better
|
Better than the National Rate · Eligible stays 168 · Observed rate 76.19% · Lower 95% interval 67.02% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 88.24% |
95.27%
7 pts worse
|
Numerator 75 · Denominator 85 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 85 |
| Discharge self-care score | 64.86% |
53.69%
11.2 pts better
|
Numerator 48 · Denominator 74 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 37 · Denominator 74 |
| Pressure ulcers or injuries, new or worsened | 3.53% |
2.29%
1.2 pts worse
|
Numerator 3 · Denominator 85 · Adjusted rate 4.99% |
| Healthcare-associated infections requiring hospitalization | 5.34% |
7.12%
1.8 pts better
|
No Different than the National Rate · Eligible stays 98 · Observed rate 1.02% · Lower 95% interval 2.83% |
| Staff COVID-19 vaccination coverage | 39.13% |
8.2%
30.9 pts better
|
Numerator 36 · Denominator 92 |
| Staff flu vaccination coverage | 26.82% |
42%
15.2 pts worse
|
Numerator 59 · Denominator 220 |
| Discharge function score | 70.27% |
56.45%
13.8 pts better
|
Numerator 52 · Denominator 74 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 66 · Denominator 66 |
| Resident COVID-19 vaccinations up to date | 65.96% |
25.2%
40.8 pts better
|
Numerator 31 · Denominator 47 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
95.5%
3 pts better
|
93.4%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 98.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
2.4%
2.4 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.5% |
4.7%
0.2 pts better
|
11.4%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.5% |
| Percentage of long-stay residents who lose too much weight | 7.8% |
5.0%
2.8 pts worse
|
5.4%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 1.9% |
12.5%
10.6 pts better
|
19.6%
17.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.3% |
14.7%
12.4 pts better
|
16.7%
14.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.3% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.0% |
15.8%
2.8 pts better
|
14.9%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 6.6% |
1.7%
4.9 pts worse
|
1.0%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.0%
2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.7% |
22.2%
2.5 pts worse
|
19.8%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.7% |
| Percentage of long-stay residents with pressure ulcers | 13.5% |
6.5%
7 pts worse
|
5.1%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
85.4%
14.6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.7% |
15.1%
10.4 pts better
|
12.0%
7.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.7% · Observed 3.9% · Expected 9.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.7%
1.3 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.1% |
81.2%
11.9 pts better
|
79.7%
13.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 11.2% |
21.6%
10.4 pts better
|
23.9%
12.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.2% · Observed 7.9% · Expected 16.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-13 · Fire 2024-06-13
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2023-03-13 · Fire 2023-03-13
13 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
5 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-10-10
F · Potential for more than minimal harm
2024-06-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-06-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-07-24
F · Potential for more than minimal harm
2023-03-13
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-04-26
F · Potential for more than minimal harm
2023-03-13
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-04-26
F · Potential for more than minimal harm
2023-03-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-04-26
E · Potential for more than minimal harm
2023-03-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-03-13
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-04-26
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-10
D · Potential for more than minimal harm
2025-09-05
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 2025-10-10
D · Potential for more than minimal harm
2024-06-13
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-06-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-24
D · Potential for more than minimal harm
2023-03-13
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-03-13
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 2023-04-26
D · Potential for more than minimal harm
2023-03-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-03-13
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 2023-04-26
D · Potential for more than minimal harm
2023-03-13
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-03-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-03-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-03-13
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 2023-04-26
D · Potential for more than minimal harm
2023-03-13
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 2023-04-26
D · Potential for more than minimal harm
2023-03-13
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-03-13
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 2023-04-26
D · Potential for more than minimal harm
2023-03-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-03-13
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-04-26
Penalties and ownership
What sits behind the stars
Ownership
Ellis, Michael
Corporate Director · Individual
Fuller, Thomas
Corporate Director · Individual
Johnson, Lynn
Corporate Director · Individual
Mclaughlin, Kathleen
Corporate Director · Individual
Mufg Union Bank Na
5% Or Greater Security Interest · Organization
Neal, Michelle
Corporate Director · Individual
Pacific Retirement Services Inc
Operational/Managerial Control · Organization
Platte, Susan
W-2 Managing Employee · Individual
Sholty, Eric
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Laurelhurst Post Acute & Rehabilitation
Portland, OR
3-star overall rating with 2-star inspections with abuse icon flag with $33,319 in total fines with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Providence Child Center
Portland, OR
5-star overall rating with 5-star inspections with $13,286 in total fines with 1 fire-safety deficiencies in the latest cycle
#3
Belmont Care And Rehabilitation
Portland, OR
2-star overall rating with 2-star inspections with abuse icon flag with 16 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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