Cycle 1
Health 2025-03-14 · Fire 2025-03-14
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Portland, OR
Laurelhurst Post Acute & Rehabilitation
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
3060 Se Stark Street, Portland, OR
(503) 535-4700
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
159
Certified beds
Average residents
94
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avamere
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
33 facilities
Chain averages 3 overall / 3 health / 4 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
0.96
Registered nurse staffing · state 0.68 · national 0.68
LPN hours / resident day
0.80
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
3.36
Nurse aide staffing · state 3.37 · national 2.35
Total nurse hours
5.12
All reported nurse hours · state 4.95 · national 3.89
Licensed hours
1.76
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
4.55
Weekend nurse staffing · state 4.39 · national 3.43
Weekend RN hours
0.67
Weekend registered nurse coverage · state 0.44 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.98
CMS adjusted RN staffing hours
Adjusted total hours
5.23
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 53% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,830
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
53.72
Composite VBP score used to determine payment impact.
Payment multiplier
1.0085
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.95
Baseline 20.62% · Performance 19.60% · Measure score 3.95 · Achievement 3.95 · Improvement 2.33
Healthcare-associated infections
7.16
Baseline 5.08% · Performance 5.69% · Measure score 7.16 · Achievement 7.16 · Improvement 0
Total nurse turnover
3.42
Baseline 59.01% · Performance 49.68% · Measure score 3.42 · Achievement 3.42 · Improvement 2.23
Adjusted total nurse staffing
6.95
Baseline 5.13 hours · Performance 5.06 hours · Measure score 6.95 · Achievement 6.95 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.03% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 68 · Observed rate 8.82% · Lower 95% interval 6.43% |
| Discharge to community | 57.92% |
50.57%
7.4 pts better
|
No Different than the National Rate · Eligible stays 74 · Observed rate 51.35% · Lower 95% interval 47.94% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 40 · Denominator 40 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 40 |
| Discharge self-care score | 38.71% |
53.69%
15 pts worse
|
Numerator 12 · Denominator 31 |
| Discharge mobility score | 58.06% |
50.94%
7.1 pts better
|
Numerator 18 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 2.5% |
2.29%
0.2 pts worse
|
Numerator 1 · Denominator 40 · Adjusted rate 3.23% |
| Healthcare-associated infections requiring hospitalization | 5.69% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 44 · Observed rate 0% · Lower 95% interval 2.83% |
| Staff COVID-19 vaccination coverage | 11.88% |
8.2%
3.7 pts better
|
Numerator 24 · Denominator 202 |
| Staff flu vaccination coverage | 28.69% |
42%
13.3 pts worse
|
Numerator 68 · Denominator 237 |
| Discharge function score | 51.61% |
56.45%
4.8 pts worse
|
Numerator 16 · Denominator 31 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 23 · Denominator 23 |
| Resident COVID-19 vaccinations up to date | 43.48% |
25.2%
18.3 pts better
|
Numerator 10 · Denominator 23 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
95.5%
1.3 pts better
|
93.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.2% · Q2 96.8% · Q3 98.5% · Q4 98.4% · 4Q avg 96.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.5% |
95.2%
3.3 pts better
|
95.5%
3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.2% |
2.4%
1.2 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.6% · Q3 1.5% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.6% |
4.7%
1.1 pts better
|
11.4%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 5.5% · Q3 3.2% · Q4 1.8% · 4Q avg 3.6% |
| Percentage of long-stay residents who lose too much weight | 3.1% |
5.0%
1.9 pts better
|
5.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 3.7% · Q3 1.6% · Q4 1.7% · 4Q avg 3.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.0% |
12.5%
5.5 pts better
|
19.6%
12.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 3.6% · Q3 6.5% · Q4 10.3% · 4Q avg 7.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.8% |
14.7%
0.1 pts worse
|
16.7%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 17.8% · Q3 17.0% · Q4 13.3% · 4Q avg 14.8% · 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 | 18.0% |
15.8%
2.2 pts worse
|
14.9%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 18.0% · Q3 14.3% · Q4 20.8% · 4Q avg 18.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
1.7%
0.9 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
2.0%
0.8 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.9% · Q4 1.6% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.9% |
22.2%
5.7 pts worse
|
19.8%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 18.9% · Q3 36.9% · Q4 31.2% · 4Q avg 27.9% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
6.5%
2.8 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 3.7% · Q3 4.2% · Q4 4.3% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.0% |
85.4%
9.6 pts better
|
81.7%
13.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.2% · Q2 94.4% · Q3 96.4% · Q4 97.0% · 4Q avg 95.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.6% |
15.1%
1.5 pts better
|
12.0%
1.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.6% · Observed 13.2% · Expected 10.8% · 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 1.2% · Q2 0.0% · Q3 0.0% · Q4 0.5% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.2% |
81.2%
2 pts better
|
79.7%
3.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.0% |
21.6%
4.4 pts worse
|
23.9%
2.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.0% · Observed 23.7% · Expected 21.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-06 · Fire 2023-11-06
26 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2022-10-21 · Fire 2022-10-21
7 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-03-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-20
D · Potential for more than minimal harm
2023-11-06
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-12-20
D · Potential for more than minimal harm
2022-10-21
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-10-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-08
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-11-04
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-12-08
D · Potential for more than minimal harm
2025-11-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-08
D · Potential for more than minimal harm
2025-09-08
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-10-14
E · Potential for more than minimal harm
2025-03-14
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 2025-04-20
E · Potential for more than minimal harm
2025-03-14
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 2025-04-20
D · Potential for more than minimal harm
2025-03-14
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-04-20
D · Potential for more than minimal harm
2025-03-14
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-04-20
D · Potential for more than minimal harm
2025-03-14
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 2025-04-20
D · Potential for more than minimal harm
2025-03-14
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 2025-04-20
D · Potential for more than minimal harm
2025-03-14
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-04-20
D · Potential for more than minimal harm
2024-10-31
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 2024-11-25
G · Actual harm
2023-11-06
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 2023-12-20
G · Actual harm
2023-11-06
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 2023-12-20
G · Actual harm
2023-11-06
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 2023-12-20
E · Potential for more than minimal harm
2023-11-06
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2023-12-20
E · Potential for more than minimal harm
2023-11-06
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 2023-12-20
E · Potential for more than minimal harm
2023-11-06
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 2023-12-20
E · Potential for more than minimal harm
2023-11-06
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 2023-12-20
E · Potential for more than minimal harm
2023-11-06
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-12-20
E · Potential for more than minimal harm
2023-11-06
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-12-20
E · Potential for more than minimal harm
2023-11-06
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 2023-12-20
E · Potential for more than minimal harm
2023-11-06
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 2023-12-20
E · Potential for more than minimal harm
2023-11-06
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-11-06
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-11-06
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-11-06
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-11-06
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-11-06
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-11-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-11-06
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 2023-12-20
D · Potential for more than minimal harm
2023-11-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-11-06
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-11-06
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-11-06
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 2023-12-20
D · Potential for more than minimal harm
2023-11-06
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-11-06
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-12-20
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 2022-12-08
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 2022-12-08
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 2022-12-08
D · Potential for more than minimal 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 2022-12-08
D · Potential for more than minimal harm
2022-10-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-10-21
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-10-21
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-12-08
Penalties and ownership
What sits behind the stars
$33,319
2023-11-03
Fine
Fine · fine $33,319
Fine
Ownership
Nearby options
Other facilities in reach
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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
#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
Holladay Park Plaza
Portland, OR
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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