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
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
0.90
Registered nurse staffing · state 0.68 · national 0.68
LPN hours / resident day
0.78
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
3.90
Nurse aide staffing · state 3.37 · national 2.35
Total nurse hours
5.59
All reported nurse hours · state 4.95 · national 3.89
Licensed hours
1.69
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
5.05
Weekend nurse staffing · state 4.39 · national 3.43
Weekend RN hours
0.45
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
0.94
CMS adjusted RN staffing hours
Adjusted total hours
5.79
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
32%
Annual RN turnover · state 53% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,759
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
47.94
Composite VBP score used to determine payment impact.
Payment multiplier
1.0016
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.01
Baseline 16.95% · Performance 18.18% · Measure score 7.01 · Achievement 7.01 · Improvement 0
Healthcare-associated infections
0
Baseline 6.00% · Performance 7.76% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.57
Baseline 39.77% · Performance 49.09% · Measure score 3.57 · Achievement 3.57 · Improvement 0
Adjusted total nurse staffing
8.59
Baseline 3.58 hours · Performance 5.52 hours · Measure score 8.59 · Achievement 8.59 · Improvement 8.33
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.47% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 172 · Observed rate 6.4% · Lower 95% interval 6.85% |
| Discharge to community | 65.33% |
50.57%
14.8 pts better
|
Better than the National Rate · Eligible stays 189 · Observed rate 63.49% · Lower 95% interval 58.38% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 96.03% |
95.27%
0.8 pts better
|
Numerator 121 · Denominator 126 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 126 |
| Discharge self-care score | 61.7% |
53.69%
8 pts better
|
Numerator 58 · Denominator 94 |
| Discharge mobility score | 55.32% |
50.94%
4.4 pts better
|
Numerator 52 · Denominator 94 |
| Pressure ulcers or injuries, new or worsened | 5.56% |
2.29%
3.3 pts worse
|
Numerator 7 · Denominator 126 · Adjusted rate 6.23% |
| Healthcare-associated infections requiring hospitalization | 7.76% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 135 · Observed rate 7.41% · Lower 95% interval 4.91% |
| Staff COVID-19 vaccination coverage | 21.54% |
8.2%
13.3 pts better
|
Numerator 53 · Denominator 246 |
| Staff flu vaccination coverage | 55.65% |
42%
13.6 pts better
|
Numerator 138 · Denominator 248 |
| Discharge function score | 60.64% |
56.45%
4.2 pts better
|
Numerator 57 · Denominator 94 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 28 · Denominator 28 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 83 · Denominator 83 |
| Resident COVID-19 vaccinations up to date | 62.5% |
25.2%
37.3 pts better
|
Numerator 45 · Denominator 72 |
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 · Adjusted 1.6 · Observed 1.5 · Expected 1.7 · Used in QM five-star |
| 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 · Adjusted 1.0 · Observed 0.8 · Expected 1.4 · Used in QM five-star |
| 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 · Q1 93.0% · Q2 82.5% · Q3 95.7% · Q4 95.0% · 4Q avg 91.6% |
| 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 · 4Q avg 98.0% |
| 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 · Q1 3.0% · Q2 2.1% · Q3 3.2% · Q4 4.0% · 4Q avg 3.1% · 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 0.0% · Q2 5.2% · Q3 3.4% · Q4 5.8% · 4Q avg 3.6% |
| 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 · Q1 1.2% · Q2 1.1% · Q3 2.3% · Q4 3.3% · 4Q avg 2.0% |
| 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 · Q1 5.8% · Q2 11.2% · Q3 10.3% · Q4 7.7% · 4Q avg 8.8% |
| 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 · Q1 17.1% · Q2 17.5% · Q3 13.9% · Q4 13.9% · 4Q avg 15.6% · 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 | 20.7% |
24.1%
3.4 pts better
|
16.3%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 25.4% · Q3 17.1% · Q4 23.4% · 4Q avg 20.7% · Used in QM five-star |
| 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 · Q1 19.2% · Q2 18.5% · Q3 11.1% · Q4 11.0% · 4Q avg 15.1% · Used in QM five-star |
| 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 · Q1 4.4% · Q2 3.0% · Q3 2.7% · Q4 3.5% · 4Q avg 3.4% · Used in QM five-star |
| 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 · Q1 2.0% · Q2 2.1% · Q3 2.1% · Q4 1.0% · 4Q avg 1.8% · Used in QM five-star |
| 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 · Q1 24.5% · Q2 20.8% · Q3 27.5% · Q4 13.0% · 4Q avg 21.3% |
| 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 · Q1 2.7% · Q2 1.9% · Q3 3.9% · Q4 1.7% · 4Q avg 2.5% · Used in QM five-star |
| 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 · Q1 90.0% · Q2 77.8% · Q3 81.7% · Q4 86.6% · 4Q avg 83.9% |
| 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 · Adjusted 10.7% · Observed 9.4% · Expected 9.8% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.8% · Q4 2.0% · 4Q avg 0.8% · Used in QM five-star |
| 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 · 4Q avg 76.8% |
| 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 · Adjusted 19.0% · Observed 15.1% · Expected 18.9% · Used in QM five-star |
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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