12 health deficiencies
Top issue: Resident Rights (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Portland, OR
2-star overall rating with 2-star inspections with abuse icon flag with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
745 Ne 122nd Avenue, Portland, OR
(503) 252-0241
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
Beds
83
Certified beds
Average residents
73
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 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
RN hours / resident day
0.40
Registered nurse staffing · state 0.68 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
3.31
Nurse aide staffing · state 3.37 · national 2.35
Total nurse hours
4.53
All reported nurse hours · state 4.95 · national 3.89
Licensed hours
1.23
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
4.01
Weekend nurse staffing · state 4.39 · national 3.43
Weekend RN hours
0.23
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
0.49
CMS adjusted RN staffing hours
Adjusted total hours
5.48
CMS adjusted total nurse staffing hours
Case-mix index
1.13
Higher values indicate more complex resident acuity
RN turnover
55%
Annual RN turnover · state 53% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Program rank
2,113
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
51.68
Composite VBP score used to determine payment impact.
Payment multiplier
1.0061
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
1.85
Baseline 43.04% · Performance 56.12% · Measure score 1.85 · Achievement 1.85 · Improvement 0
Adjusted total nurse staffing
8.49
Baseline 4.59 hours · Performance 5.49 hours · Measure score 8.49 · Achievement 8.49 · Improvement 7.08
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.4% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 41 · Observed rate 9.76% · Lower 95% interval 7.09% |
| Discharge to community | 51% |
50.57%
0.4 pts better
|
No Different than the National Rate · Eligible stays 39 · Observed rate 46.15% · Lower 95% interval 37.37% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 42 · Denominator 42 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 42 |
| Discharge self-care score | 30.77% |
53.69%
22.9 pts worse
|
Numerator 8 · Denominator 26 |
| Discharge mobility score | 15.38% |
50.94%
35.6 pts worse
|
Numerator 4 · Denominator 26 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 42 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 126 |
| Staff flu vaccination coverage | 16.79% |
42%
25.2 pts worse
|
Numerator 23 · Denominator 137 |
| Discharge function score | 46.15% |
56.45%
10.3 pts worse
|
Numerator 12 · Denominator 26 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 20 · Denominator 20 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 27 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.8% |
95.5%
0.7 pts worse
|
93.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.1% · Q2 92.3% · Q3 94.3% · Q4 96.3% · 4Q avg 94.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 84.7% |
95.2%
10.5 pts worse
|
95.5%
10.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 84.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
2.4%
0.9 pts worse
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.9% · Q3 5.7% · Q4 3.7% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.5% |
4.7%
4.2 pts better
|
11.4%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 4Q avg 0.5% |
| Percentage of long-stay residents who lose too much weight | 0.7% |
5.0%
4.3 pts better
|
5.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.5% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.0% |
12.5%
1.5 pts better
|
19.6%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 12.5% · Q3 8.7% · Q4 12.2% · 4Q avg 11.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.1% |
14.7%
0.6 pts better
|
16.7%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 14.7% · Q3 18.4% · Q4 11.4% · 4Q avg 14.1% · 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 | 32.4% |
24.1%
8.3 pts worse
|
16.3%
16.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 32.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.8% |
15.8%
3 pts better
|
14.9%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 8.3% · Q3 11.1% · Q4 14.3% · 4Q avg 12.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
1.7%
0.8 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.9% · Q4 1.6% · 4Q avg 0.9% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.3% |
22.2%
0.1 pts worse
|
19.8%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.9% · Q2 29.9% · Q3 15.9% · Q4 21.6% · 4Q avg 22.3% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
6.5%
2.5 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.6% · Q3 6.0% · Q4 4.3% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 58.8% |
85.4%
26.6 pts worse
|
81.7%
22.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 76.0% · Q2 56.9% · Q3 55.1% · Q4 47.6% · 4Q avg 58.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.2% |
15.1%
4.1 pts worse
|
12.0%
7.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.2% · Observed 20.8% · Expected 12.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.7%
0.1 pts better
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.4% · Q3 1.2% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 36.0% |
81.2%
45.2 pts worse
|
79.7%
43.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 36.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.1% |
21.6%
4.5 pts better
|
23.9%
6.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.1% · Observed 16.7% · Expected 23.2% · Used in QM five-star |
Survey summary
Top issue: Resident Rights (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire Safety
Have an externally vented heating system.
Corrected 2026-02-10
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-03-14
Fire Safety
Have an externally vented heating system.
Corrected 2025-03-14
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-03-14
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-14
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-12-13
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-12-13
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-09-12
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-12
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2023-09-12
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-09-12
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-09-12
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2019-07-31
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2019-07-31
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-07-31
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-11-04
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-07-31
Fire Safety
Meet other general requirements.
Corrected 2019-07-31
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-07-31
Fire Safety
Provide emergency officials' contact information.
Corrected 2019-07-31
Fire Safety
Provide primary/alternate means for communication.
Corrected 2019-07-31
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 2019-07-31
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-08-13
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-07-31
Inspection history
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-12-13
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 2024-12-13
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 2024-12-13
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 2024-12-13
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-13
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-12-13
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-12-13
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-12-13
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-12-13
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 2024-12-13
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-13
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-12-13
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-12-13
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-29
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-06-28
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-13
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 2023-09-13
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-09-13
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-13
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-09-13
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-13
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 2023-09-13
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2023-06-27
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-27
Health
Provide and implement an infection prevention and control program.
Corrected 2019-07-31
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 2019-07-31
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2019-07-31
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-08-31
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-07-31
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-07-31
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-07-31
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2019-07-31
Penalties and ownership
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
5% Or Greater Security Interest · Organization
Nearby options
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Portland, OR
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Portland, OR
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
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