13 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Oregon City, OR
3-star overall rating with 3-star inspections with $18,075 in total fines with 13 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
148 Hood Street, Oregon City, OR
(503) 656-4035
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
53
Certified beds
Average residents
50
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1994-06-22
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
0.28
Registered nurse staffing · state 0.68 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
3.11
Nurse aide staffing · state 3.37 · national 2.35
Total nurse hours
4.32
All reported nurse hours · state 4.95 · national 3.89
Licensed hours
1.21
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.97
Weekend nurse staffing · state 4.39 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.44 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.32
CMS adjusted RN staffing hours
Adjusted total hours
4.85
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
70%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Program rank
8,307
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.18
Composite VBP score used to determine payment impact.
Payment multiplier
0.9845
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
0
Baseline 55.81% · Performance 75.00% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
5.44
Baseline 4.46 hours · Performance 4.62 hours · Measure score 5.44 · Achievement 5.44 · Improvement 0.72
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 9 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 7 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 16 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 6 · 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 48 |
| Staff flu vaccination coverage | 72.92% |
42%
30.9 pts better
|
Numerator 35 · Denominator 48 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.7% |
95.5%
0.2 pts better
|
93.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.2% · Q3 92.1% · Q4 94.1% · 4Q avg 95.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.6% |
95.2%
2.4 pts better
|
95.5%
2.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.4% |
2.4%
1 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 2.8% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.7% |
4.7%
2 pts better
|
11.4%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.6% · Q3 3.2% · Q4 3.6% · 4Q avg 2.7% |
| Percentage of long-stay residents who lose too much weight | 1.6% |
5.0%
3.4 pts better
|
5.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 0.0% · Q4 2.9% · 4Q avg 1.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.3% |
12.5%
3.2 pts better
|
19.6%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 14.7% · Q3 5.4% · Q4 5.9% · 4Q avg 9.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.3% |
14.7%
1.4 pts better
|
16.7%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 20.8% · Q3 11.1% · Q4 12.5% · 4Q avg 13.3% · 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 | 24.9% |
24.1%
0.8 pts worse
|
16.3%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.3% |
15.8%
0.5 pts worse
|
14.9%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 21.9% · Q3 17.1% · Q4 21.2% · 4Q avg 16.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.8% |
1.7%
1.1 pts worse
|
1.0%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 3.0% · Q4 8.2% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
2.0%
1.3 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.8% |
22.2%
2.6 pts worse
|
19.8%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 30.6% · Q3 25.8% · Q4 22.0% · 4Q avg 24.8% |
| Percentage of long-stay residents with pressure ulcers | 9.5% |
6.5%
3 pts worse
|
5.1%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 14.3% · Q3 6.8% · Q4 2.9% · 4Q avg 9.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 68.3% |
85.4%
17.1 pts worse
|
81.7%
13.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 66.1% · Q2 72.1% · Q3 72.2% · Q4 63.1% · 4Q avg 68.3% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.7%
1.1 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.9% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 69.0% |
81.2%
12.2 pts worse
|
79.7%
10.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 69.0% |
Survey summary
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Top issue: Nursing and Physician Services (2 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-15
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-11-15
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-15
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-08-15
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2022-10-06
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2022-10-06
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-06
Fire Safety
Ensure that suites are correctly sub-divided by noncombustible or limited-combustible construction.
Corrected 2022-10-06
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-10-06
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2022-10-06
Inspection history
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-12
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-19
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-19
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-11-15
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 2024-11-15
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-11-15
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-11-15
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-11-15
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-11-15
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-11-15
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 2024-11-15
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-15
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 2024-11-15
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-08-15
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 2023-08-15
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-15
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-08-15
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 2023-08-15
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-08-15
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2022-10-06
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-10-06
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-10-06
Health
Implement a program that monitors antibiotic use.
Corrected 2022-10-06
Penalties and ownership
Fine · fine $18,075
Fine
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
5% Or Greater Security Interest · Organization
Nearby options
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West Linn, OR
4-star overall rating with 5-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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