Cycle 1
Health 2025-02-03 · Fire 2025-02-03
28 health deficiencies
Top issue: Resident Rights (8 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Gresham, OR
Village Health Care
1-star overall rating with 1-star inspections with $4,225 in total fines with 28 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
3955 Se 182nd Avenue, Gresham, OR
(503) 665-0183
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
106
Certified beds
Average residents
73
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Evergreen Healthcare Group
Operator or chain grouping
Approved since
1967-04-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
41 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 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
0.48
Registered nurse staffing · state 0.68 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
3.54
Nurse aide staffing · state 3.37 · national 2.35
Total nurse hours
4.90
All reported nurse hours · state 4.95 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
4.55
Weekend nurse staffing · state 4.39 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.44 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
5.15
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
2,942
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.79
Composite VBP score used to determine payment impact.
Payment multiplier
1.0002
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.01
Baseline 19.10% · Performance 19.11% · Measure score 5.01 · Achievement 5.01 · Improvement 0
Healthcare-associated infections
2.49
Baseline 5.78% · Performance 7.09% · Measure score 2.49 · Achievement 2.49 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
6.54
Baseline 5.28 hours · Performance 4.94 hours · Measure score 6.54 · Achievement 6.54 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.29% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 139 · Observed rate 12.23% · Lower 95% interval 8% |
| Discharge to community | 54.97% |
50.57%
4.4 pts better
|
No Different than the National Rate · Eligible stays 153 · Observed rate 49.02% · Lower 95% interval 48.28% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 72.41% |
95.27%
22.9 pts worse
|
Numerator 63 · Denominator 87 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 87 |
| Discharge self-care score | 43.28% |
53.69%
10.4 pts worse
|
Numerator 29 · Denominator 67 |
| Discharge mobility score | 35.82% |
50.94%
15.1 pts worse
|
Numerator 24 · Denominator 67 |
| Pressure ulcers or injuries, new or worsened | 1.15% |
2.29%
1.1 pts better
|
Numerator 1 · Denominator 87 · Adjusted rate 1.38% |
| Healthcare-associated infections requiring hospitalization | 7.09% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 78 · Observed rate 6.41% · Lower 95% interval 4.19% |
| Staff COVID-19 vaccination coverage | 5.98% |
8.2%
2.2 pts worse
|
Numerator 7 · Denominator 117 |
| Staff flu vaccination coverage | 39.09% |
42%
2.9 pts worse
|
Numerator 43 · Denominator 110 |
| Discharge function score | 43.28% |
56.45%
13.2 pts worse
|
Numerator 29 · Denominator 67 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 22 · Denominator 22 |
| Transfer of health information to patient | 96.36% |
96.28%
0.1 pts better
|
Numerator 53 · Denominator 55 |
| Resident COVID-19 vaccinations up to date | 17.39% |
25.2%
7.8 pts worse
|
Numerator 8 · Denominator 46 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 65.8% |
95.5%
29.7 pts worse
|
93.4%
27.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 91.2% · Q2 58.6% · Q3 61.5% · Q4 55.3% · 4Q avg 65.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 71.4% |
95.2%
23.8 pts worse
|
95.5%
24.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 71.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
2.4%
0.3 pts worse
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.4% · Q3 2.6% · Q4 2.1% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.0% |
4.7%
2.7 pts better
|
11.4%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q3 0.0% · Q4 6.5% · 4Q avg 2.0% |
| Percentage of long-stay residents who lose too much weight | 10.2% |
5.0%
5.2 pts worse
|
5.4%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 11.5% · Q3 7.9% · Q4 11.6% · 4Q avg 10.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.1% |
12.5%
0.4 pts better
|
19.6%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 3.6% · Q3 13.2% · Q4 6.8% · 4Q avg 12.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.9% |
14.7%
1.8 pts better
|
16.7%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 15.0% · Q3 13.3% · Q4 10.0% · 4Q avg 12.9% · 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 | 41.2% |
24.1%
17.1 pts worse
|
16.3%
24.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 41.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.3% |
15.8%
3.5 pts worse
|
14.9%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 29.6% · Q3 11.4% · Q4 26.2% · 4Q avg 19.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.5% |
1.7%
1.8 pts worse
|
1.0%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.8% · Q3 5.6% · Q4 3.4% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.5% |
2.0%
3.5 pts worse
|
1.7%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.4% · Q3 10.3% · Q4 4.3% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.1% |
22.2%
1.1 pts better
|
19.8%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.0% · Q2 35.6% · Q3 10.5% · Q4 23.6% · 4Q avg 21.1% |
| Percentage of long-stay residents with pressure ulcers | 5.2% |
6.5%
1.3 pts better
|
5.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 4.6% · Q4 11.1% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 39.4% |
85.4%
46 pts worse
|
81.7%
42.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 73.7% · Q2 47.2% · Q3 16.8% · Q4 16.4% · 4Q avg 39.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.1% |
15.1%
4 pts better
|
12.0%
0.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.1% · Observed 11.0% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.7%
0.5 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.6% · Q3 0.0% · Q4 1.8% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 35.5% |
81.2%
45.7 pts worse
|
79.7%
44.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 35.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 11.2% |
21.6%
10.4 pts better
|
23.9%
12.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.2% · Observed 11.0% · Expected 23.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-08 · Fire 2023-09-08
6 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-11-14 · Fire 2019-11-14
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-03
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-02-03
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-02-03
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-03
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-02-20
F · Potential for more than minimal harm
2019-11-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2020-01-03
F · Potential for more than minimal harm
2019-11-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2020-01-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-12-01
G · Actual harm
2025-05-22
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-05-30
F · Potential for more than minimal harm
2025-02-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-21
E · Potential for more than minimal harm
2025-02-03
F572 · Resident Rights Deficiencies
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2025-03-21
E · Potential for more than minimal harm
2025-02-03
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2025-03-21
E · Potential for more than minimal harm
2025-02-03
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-03-21
E · Potential for more than minimal harm
2025-02-03
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-03-21
E · Potential for more than minimal harm
2025-02-03
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 2025-03-21
E · Potential for more than minimal harm
2025-02-03
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 2025-03-21
D · Potential for more than minimal harm
2025-02-03
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 2025-03-21
D · Potential for more than minimal harm
2025-02-03
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-03
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-03
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-03
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-03
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-03
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-03
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-03
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 2025-03-21
D · Potential for more than minimal harm
2025-02-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-03
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-03
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-03
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-03
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-03
F756 · Pharmacy Service Deficiencies
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 2025-03-21
D · Potential for more than minimal harm
2025-02-03
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 2025-03-21
D · Potential for more than minimal harm
2025-02-03
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-03-21
C · Minimal harm
2025-02-03
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-03-21
E · Potential for more than minimal harm
2023-09-08
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 2023-10-28
E · Potential for more than minimal harm
2023-09-08
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-10-28
D · Potential for more than minimal harm
2023-09-08
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 2023-10-28
D · Potential for more than minimal harm
2023-09-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-28
D · Potential for more than minimal harm
2023-09-08
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-10-28
D · Potential for more than minimal harm
2023-09-08
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-10-28
D · Potential for more than minimal harm
2023-09-08
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 2023-10-28
D · Potential for more than minimal harm
2019-11-14
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 2020-01-03
D · Potential for more than minimal harm
2019-11-14
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2020-01-03
D · Potential for more than minimal harm
2019-11-14
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 2020-01-03
D · Potential for more than minimal harm
2019-11-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-01-03
Penalties and ownership
What sits behind the stars
$4,225
2025-05-22
Fine
Fine · fine $4,225
Fine
Ownership
Couve Financial Services LLC
Operational/Managerial Control · Organization
Couve Healthcare Consulting LLC
Operational/Managerial Control · Organization
Morris, Christopher
Operational/Managerial Control · Individual
Odenthal, Jason
Operational/Managerial Control · Individual
Perlman, Harold
Operational/Managerial Control · Individual
Rutledge, Margo
Operational/Managerial Control · Individual
Spielman, Shimon
Operational/Managerial Control · Individual
Veach, Dakota
Operational/Managerial Control · Individual
Village Opco Manager LLC
Operational/Managerial Control · Organization
Village SNF Consulting LLC
Operational/Managerial Control · Organization
Village SNF Operations LLC
Operational/Managerial Control · Organization
Yenowitz, Yitzchok
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Marquis Centennial Post Acute Rehab
Portland, OR
5-star overall rating with 4-star inspections with $10,033 in total fines with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Cedar Crossings
Portland, OR
2-star overall rating with 1-star inspections with $44,133 in total fines with 15 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Avalon Care Center - Portland
Portland, OR
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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