Portland, OR

Menlo Park Post Acute

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

Compare this facility

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

Facility snapshot

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

Hours and turnover

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

Value-based purchasing

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

How the VBP score is built

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

Medicare quality reporting measures

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

Resident outcomes and process scores

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

Recent inspection cycles

Cycle 1 Health 2024-11-08 · Fire 2024-11-08

12 health deficiencies

Top issue: Resident Rights (4 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2023-07-31 · Fire 2023-07-31

10 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

9 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2019-07-01 · Fire 2019-07-01

10 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

12 fire-safety deficiencies

Top issue: Smoke (6 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2026-01-28

K522 · Services Deficiencies

Fire Safety

Have an externally vented heating system.

Corrected 2026-02-10

F · Potential for more than minimal harm 2025-01-29

E15 · Emergency Preparedness Deficiencies

Fire Safety

Address subsistence needs for staff and patients.

Corrected 2025-03-14

F · Potential for more than minimal harm 2025-01-29

K522 · Services Deficiencies

Fire Safety

Have an externally vented heating system.

Corrected 2025-03-14

F · Potential for more than minimal harm 2025-01-29

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Corrected 2025-03-14

F · Potential for more than minimal harm 2025-01-29

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-03-14

F · Potential for more than minimal harm 2024-11-08

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-11-08

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2024-12-13

F · Potential for more than minimal harm 2023-07-31

K223 · Egress Deficiencies

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

F · Potential for more than minimal harm 2023-07-31

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-09-12

F · Potential for more than minimal harm 2023-07-31

K344 · Smoke Deficiencies

Fire Safety

Have an alternate power supply for its alarm system.

Corrected 2023-09-12

D · Potential for more than minimal harm 2023-07-31

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2023-09-12

D · Potential for more than minimal harm 2023-07-31

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2023-09-12

F · Potential for more than minimal harm 2019-07-01

E18 · Emergency Preparedness Deficiencies

Fire Safety

Establish procedures for tracking staff and patients during an emergency.

Corrected 2019-07-31

F · Potential for more than minimal harm 2019-07-01

K223 · Egress Deficiencies

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

F · Potential for more than minimal harm 2019-07-01

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2019-07-31

F · Potential for more than minimal harm 2019-07-01

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2019-11-04

F · Potential for more than minimal harm 2019-07-01

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2019-07-31

F · Potential for more than minimal harm 2019-07-01

K932 · Smoke Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2019-07-31

E · Potential for more than minimal harm 2019-07-01

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2019-07-31

D · Potential for more than minimal harm 2019-07-01

E31 · Emergency Preparedness Deficiencies

Fire Safety

Provide emergency officials' contact information.

Corrected 2019-07-31

D · Potential for more than minimal harm 2019-07-01

E32 · Emergency Preparedness Deficiencies

Fire Safety

Provide primary/alternate means for communication.

Corrected 2019-07-31

D · Potential for more than minimal harm 2019-07-01

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 2019-07-31

D · Potential for more than minimal harm 2019-07-01

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-08-13

D · Potential for more than minimal harm 2019-07-01

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2019-07-31

Inspection history

Recent health citations

F · Potential for more than minimal harm 2024-11-08

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2024-12-13

F · Potential for more than minimal harm 2024-11-08

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 2024-12-13

E · Potential for more than minimal harm 2024-11-08

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 2024-12-13

E · Potential for more than minimal harm 2024-11-08

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 2024-12-13

E · Potential for more than minimal harm 2024-11-08

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 2024-12-13

D · Potential for more than minimal harm 2024-11-08

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-11-08

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 2024-12-13

D · Potential for more than minimal harm 2024-11-08

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 2024-12-13

D · Potential for more than minimal harm 2024-11-08

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 2024-12-13

D · Potential for more than minimal harm 2024-11-08

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 2024-12-13

D · Potential for more than minimal harm 2024-11-08

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-11-08

F685 · Quality of Life and Care Deficiencies

Health

Assist a resident in gaining access to vision and hearing services.

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-11-08

F699 · Quality of Life and Care Deficiencies

Health

Provide care or services that was trauma informed and/or culturally competent.

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-10-08

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 2024-10-29

D · Potential for more than minimal harm 2024-06-06

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2024-06-28

F · Potential for more than minimal harm 2023-07-31

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 2023-09-13

E · Potential for more than minimal harm 2023-07-31

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 2023-09-13

D · Potential for more than minimal harm 2023-07-31

F656 · Resident Assessment and Care Planning Deficiencies

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

D · Potential for more than minimal harm 2023-07-31

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-09-13

D · Potential for more than minimal harm 2023-07-31

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2023-09-13

D · Potential for more than minimal harm 2023-07-31

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 2023-09-13

D · Potential for more than minimal harm 2023-07-31

F758 · Pharmacy Service Deficiencies

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

D · Potential for more than minimal harm 2023-06-02

F691 · Quality of Life and Care Deficiencies

Health

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Corrected 2023-06-27

D · Potential for more than minimal harm 2023-06-02

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-06-27

F · Potential for more than minimal harm 2019-07-01

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2019-07-31

E · Potential for more than minimal harm 2019-07-01

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 2019-07-31

E · Potential for more than minimal harm 2019-07-01

F727 · Nursing and Physician Services Deficiencies

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

D · Potential for more than minimal harm 2019-07-01

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2019-08-31

D · Potential for more than minimal harm 2019-07-01

F656 · Resident Assessment and Care Planning Deficiencies

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

D · Potential for more than minimal harm 2019-07-01

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2019-07-31

D · Potential for more than minimal harm 2019-07-01

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2019-07-31

C · Minimal harm 2019-07-01

F574 · Resident Rights Deficiencies

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

What sits behind the stars

Ownership

Apt, Frederick

Operational/Managerial Control · Individual

0% 252 facilities 2024-05-10
Ceesay, Ansumana

Operational/Managerial Control · Individual

0% 1 facilities 2024-09-01
Grace, Victoria

Operational/Managerial Control · Individual

0% 1 facilities 2024-11-21
Jergensen, Joshua

Operational/Managerial Control · Individual

0% 237 facilities 2024-05-10
Larson, David

Operational/Managerial Control · Individual

0% 14 facilities 2024-09-01
Mitchell, John

Operational/Managerial Control · Individual

0% 254 facilities 2024-05-10
Truist Bank

5% Or Greater Security Interest · Organization

0% 55 facilities 2024-09-01

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