Cycle 1
Health 2025-04-11 · Fire 2025-04-11
2 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Beaverton, OR
Maryville
4-star overall rating with 2-star inspections with $202,966 in total fines with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
14645 Sw Farmington Road, Beaverton, OR
(503) 643-8626
Overall
4 / 5
CMS overall stars
Health inspections
2 / 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
165
Certified beds
Average residents
137
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1985-02-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.90
Registered nurse staffing
LPN hours / resident day
0.78
Licensed practical nurse staffing
Aide hours / resident day
3.90
Nurse aide staffing
Weekend hours
5.05
Weekend nurse staffing
RN turnover
32%
Annual RN turnover
Total nurse turnover
43%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.4
0.2 pts worse
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
2.5
1.5 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.6% |
95.5%
3.9 pts worse
|
93.4%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.0% |
95.2%
2.8 pts better
|
95.5%
2.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
2.4%
0.7 pts worse
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents who lose too much weight | 2.0% |
5.0%
3 pts better
|
5.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.8% |
12.5%
3.7 pts better
|
19.6%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 15.6% |
14.7%
0.9 pts worse
|
16.7%
1.1 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 | 20.7% |
24.1%
3.4 pts better
|
16.3%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.1% |
15.8%
0.7 pts better
|
14.9%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.4% |
1.7%
1.7 pts worse
|
1.0%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
2.0%
0.2 pts better
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.3% |
22.2%
0.9 pts better
|
19.8%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.5% |
6.5%
4 pts better
|
5.1%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.9% |
85.4%
1.5 pts worse
|
81.7%
2.2 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.7% |
15.1%
4.4 pts better
|
12.0%
1.3 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.7%
0.9 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.8% |
81.2%
4.4 pts worse
|
79.7%
2.9 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.0% |
21.6%
2.6 pts better
|
23.9%
4.9 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-18 · Fire 2023-12-18
11 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2019-01-14 · Fire 2019-01-14
16 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-04-11
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-11
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-05-28
F · Potential for more than minimal harm
2023-12-18
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-02-02
F · Potential for more than minimal harm
2023-12-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-02
D · Potential for more than minimal harm
2023-12-18
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-02-02
F · Potential for more than minimal harm
2019-01-14
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2019-03-04
F · Potential for more than minimal harm
2019-01-14
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 2019-03-04
F · Potential for more than minimal harm
2019-01-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-03-04
E · Potential for more than minimal harm
2019-01-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-03-04
D · Potential for more than minimal harm
2019-01-14
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2019-03-04
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-11
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 2025-05-28
D · Potential for more than minimal harm
2025-01-03
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 2025-02-07
G · Actual harm
2024-03-20
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 2024-01-03
J · Immediate jeopardy
2023-12-18
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 2024-02-02
G · Actual harm
2023-12-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-02
D · Potential for more than minimal harm
2023-12-18
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 2024-02-02
D · Potential for more than minimal harm
2023-12-18
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 2024-02-02
D · Potential for more than minimal harm
2023-12-18
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-02-02
D · Potential for more than minimal harm
2023-12-18
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 2024-02-02
D · Potential for more than minimal harm
2023-12-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-02
D · Potential for more than minimal harm
2023-12-18
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-02-02
D · Potential for more than minimal harm
2023-12-18
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 2024-02-02
G · Actual harm
2023-08-17
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 2023-10-02
E · Potential for more than minimal harm
2023-08-17
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 2023-10-02
D · Potential for more than minimal harm
2023-08-17
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 2023-10-02
D · Potential for more than minimal harm
2023-08-17
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 2023-10-02
D · Potential for more than minimal harm
2023-08-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-02
D · Potential for more than minimal harm
2023-08-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-02
G · Actual harm
2023-04-07
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2023-05-25
G · Actual harm
2023-04-07
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-05-25
D · Potential for more than minimal harm
2023-04-07
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 2023-05-25
D · Potential for more than minimal harm
2023-04-07
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-05-25
D · Potential for more than minimal harm
2023-04-07
F772 · Administration Deficiencies
Health
Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.
Corrected 2022-05-15
D · Potential for more than minimal harm
2023-04-07
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2023-05-25
D · Potential for more than minimal harm
2023-04-07
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-05-25
D · Potential for more than minimal harm
2019-01-14
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2019-03-04
D · Potential for more than minimal harm
2019-01-14
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 2019-03-04
D · Potential for more than minimal harm
2019-01-14
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-03-04
Penalties and ownership
What sits behind the stars
$107,136
2023-12-18
Fine
Fine · fine $107,136
Fine
$55,692
2023-08-17
Fine
Fine · fine $55,692
Fine
$40,138
2023-04-07
Fine
Fine · fine $40,138
Fine
Ownership
St Mary Of Oregon Ministries Oregon
5% Or Greater Direct Ownership Interest · Organization
Altenhofen, Adele
Operational/Managerial Control · Individual
Altenhofen, Adele
Corporate Director · Individual
Baertlein, Thomas
Corporate Director · Individual
Barger, Eric
Corporate Director · Individual
Brecht, Jeff
Corporate Director · Individual
Calcagno, Kathy
Corporate Director · Individual
Cope, Bret
Operational/Managerial Control · Individual
Dolan, James
Corporate Director · Individual
Duncan, Francine
Corporate Director · Individual
Fox, Kelley
Corporate Director · Individual
Gilbert, Stephanie
Corporate Director · Individual
Parry, Kathleen
Operational/Managerial Control · Individual
Parry, Kathleen
Corporate Officer · Individual
Rask, Thomas
Corporate Director · Individual
Rodlun, Laureli
Operational/Managerial Control · Individual
St Mary Of Oregon Ministries Oregon
Operational/Managerial Control · Organization
Stewart, Bryan
Corporate Director · Individual
Vuylsteke, Leonard
Corporate Director · Individual
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