Cycle 1
Health 2025-06-26 · Fire 2025-06-26
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Portland, OR
Reedwood Post Acute
5-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
3540 Se Francis Street, Portland, OR
(503) 232-5767
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
64
Certified beds
Average residents
50
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1967-01-13
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
0.71
Registered nurse staffing · state 0.68 · national 0.68
LPN hours / resident day
0.56
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.82
Nurse aide staffing · state 3.37 · national 2.35
Total nurse hours
4.08
All reported nurse hours · state 4.95 · national 3.89
Licensed hours
1.27
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.71
Weekend nurse staffing · state 4.39 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.44 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.82
CMS adjusted RN staffing hours
Adjusted total hours
4.70
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 53% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,746
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.80
Composite VBP score used to determine payment impact.
Payment multiplier
0.9839
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 21.52% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0
Performance 8.01% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
6.14
Baseline 48.21% · Performance 38.60% · Measure score 6.14 · Achievement 6.14 · Improvement 3.62
Adjusted total nurse staffing
4.18
Baseline 4.11 hours · Performance 4.27 hours · Measure score 4.18 · Achievement 4.18 · Improvement 0.46
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.56% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 46 · Observed rate 6.52% · Lower 95% interval 6.02% |
| Discharge to community | 49.31% |
50.57%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 49 · Observed rate 51.02% · Lower 95% interval 39.51% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 38 · Denominator 38 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 38 |
| Discharge self-care score | 60.61% |
53.69%
6.9 pts better
|
Numerator 20 · Denominator 33 |
| Discharge mobility score | 57.58% |
50.94%
6.6 pts better
|
Numerator 19 · Denominator 33 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 38 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.01% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 29 · Observed rate 10.34% · Lower 95% interval 4.23% |
| Staff COVID-19 vaccination coverage | 12.33% |
8.2%
4.1 pts better
|
Numerator 9 · Denominator 73 |
| Staff flu vaccination coverage | 58.97% |
42%
17 pts better
|
Numerator 46 · Denominator 78 |
| Discharge function score | 69.7% |
56.45%
13.2 pts better
|
Numerator 23 · Denominator 33 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 21 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.5%
4.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.9% |
95.2%
0.3 pts worse
|
95.5%
0.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
2.4%
0.4 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.6% · Q4 5.1% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.7% |
4.7%
4 pts better
|
11.4%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
5.0%
5 pts better
|
5.4%
5.4 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 who received an antianxiety or hypnotic medication | 2.3% |
12.5%
10.2 pts better
|
19.6%
17.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 0.0% · Q3 0.0% · Q4 2.7% · 4Q avg 2.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.0% |
14.7%
2.7 pts better
|
16.7%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 10.3% · Q3 9.4% · Q4 5.7% · 4Q avg 12.0% · 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 | 7.9% |
24.1%
16.2 pts better
|
16.3%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 4.3% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.8% |
15.8%
11 pts better
|
14.9%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 0.0% · Q3 10.7% · Q4 3.2% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.7%
1.7 pts better
|
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% · 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 | 12.5% |
22.2%
9.7 pts better
|
19.8%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.1% · Q2 9.3% · Q3 21.3% · Q4 5.1% · 4Q avg 12.5% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
6.5%
6.5 pts better
|
5.1%
5.1 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 short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
85.4%
14 pts better
|
81.7%
17.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 98.9% · Q3 100.0% · Q4 100.0% · 4Q avg 99.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.5% |
15.1%
2.6 pts better
|
12.0%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.5% · Observed 12.5% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.5% |
1.7%
0.8 pts worse
|
1.6%
0.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 1.8% · Q3 2.0% · Q4 2.4% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
81.2%
18.8 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 4.7% |
21.6%
16.9 pts better
|
23.9%
19.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.7% · Observed 4.2% · Expected 21.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-07 · Fire 2024-03-07
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-12-05 · Fire 2022-12-05
5 health deficiencies
Top issue: Administration (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-01
D · Potential for more than minimal harm
2025-06-26
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-06-30
F · Potential for more than minimal harm
2024-03-07
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-04-03
D · Potential for more than minimal harm
2024-03-07
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 2024-04-26
D · Potential for more than minimal harm
2024-03-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-03
D · Potential for more than minimal harm
2024-03-07
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-04-03
D · Potential for more than minimal harm
2024-03-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-04-03
F · Potential for more than minimal harm
2022-12-05
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-12-02
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-03-07
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 2024-03-27
D · Potential for more than minimal harm
2024-03-07
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 2024-03-27
D · Potential for more than minimal harm
2024-03-07
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 2024-03-27
D · Potential for more than minimal harm
2024-03-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-03-07
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 2024-03-27
D · Potential for more than minimal harm
2024-03-07
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-03-27
F · Potential for more than minimal harm
2022-12-05
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 2023-01-11
F · Potential for more than minimal harm
2022-12-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-11
D · Potential for more than minimal harm
2022-12-05
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 2023-01-11
D · Potential for more than minimal harm
2022-12-05
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-01-11
D · Potential for more than minimal harm
2022-12-05
F772 · Administration Deficiencies
Health
Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.
Corrected 2023-01-11
Penalties and ownership
What sits behind the stars
Ownership
Providence Group Nh, LLC
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Operational/Managerial Control · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Jergensen, Joshua
Operational/Managerial Control · Individual
Keesey, Charli
Operational/Managerial Control · Individual
Mitchell, John
Operational/Managerial Control · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Onishi, Eriko
Operational/Managerial Control · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Thomas, Andrew
Operational/Managerial Control · Individual
Truist Bank
5% Or Greater Security Interest · Organization
Nearby options
Other facilities in reach
#1
Friendship Health Center
Portland, OR
1-star overall rating with 1-star inspections with Special Focus status with $103,564 in total fines with 27 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Laurelhurst Post Acute & Rehabilitation
Portland, OR
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
#3
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
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