Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Forest Grove Post Acute during CMS and state inspections, most recent first.
A resident with dementia and depression received PRN psychotropic medications without physician evaluation or documented rationale for use beyond 14 days. Staff were unaware of the 14-day limitation, resulting in the continuation of these medications past the required timeframe without proper review.
Two residents were not properly assessed or supervised for smoking safety as required by facility policy. One resident with COPD was listed as an independent smoker without a documented assessment and was observed disposing of a cigarette improperly. Another resident with vascular dementia, care planned for supervised smoking, was found with cigarettes in their personal belongings and was observed smoking without staff supervision, contrary to policy. Staff confirmed these lapses in assessment and supervision.
The facility failed to follow physician's orders for oxygen administration for five residents, leading to potential respiratory complications. Residents with conditions such as chronic respiratory failure, COPD, and heart failure were observed receiving incorrect oxygen levels. Staff acknowledged the discrepancies, indicating a systemic issue in adhering to prescribed respiratory care protocols.
A resident with a history of hypertension and diabetes experienced a worsening pressure ulcer due to the facility's failure to implement appropriate wound care treatments. Despite measurements being taken by an LPN and reported to the DNS, no follow-up actions or physician notifications were made, resulting in the ulcer deteriorating to a Stage 3 condition.
The facility did not conduct annual performance reviews for five CNAs, despite the expectation that these reviews occur annually. This was confirmed by the Interim Administrator during a review of personnel records.
The facility failed to ensure accurate daily staff postings for 7 out of 30 days, risking inaccurate staffing information for residents, the public, and staff. The Direct Care Staff Daily reports were incomplete, missing details such as census, staff numbers, and hours worked. The Administrator and Corporate Consultant acknowledged the issue, with the Administrator expecting staff to complete the sheets at the start of each shift.
The facility did not maintain appropriate medication storage temperatures, as temperature logs for a medication refrigerator were found blank on several dates. This oversight was acknowledged by the DNS, who stated that nurses were expected to complete these logs, potentially risking medication efficacy.
A resident with a history of shoulder pain experienced a lack of dignity and respect when an LPN failed to heed her expressed discomfort during a care procedure. Despite the resident's cognitive awareness and communication of pain, the LPN continued to lift the resident's arm, causing significant discomfort. The facility's investigation confirmed that the LPN was in a hurry and did not adhere to the resident's care plan, which emphasized avoiding rushing and listening to the resident.
A facility failed to provide a timely Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) to a resident with metabolic encephalopathy and COPD. The resident, who was cognitively intact, did not receive the SNF ABN until well after their last covered day of Medicare Part A services. The Social Services Director confirmed the delay, acknowledging the notice should have been issued on or before the last covered day, while the administrator noted a 48-hour notice is standard.
The facility failed to provide timely incontinence care for two residents, leading to delays in personal hygiene assistance. One resident, with heart failure and diabetes, experienced typical wait times of two hours for care despite using the call light. Another resident, with hepatic encephalopathy, waited over 90 minutes for assistance due to CNA confusion over room assignments. The interim administrator emphasized the expectation for prompt care and response to call lights.
Failure to Discontinue PRN Psychotropic Medications After 14 Days
Penalty
Summary
The facility failed to discontinue PRN psychotropic medication orders after 14 days for one resident who was admitted with diagnoses of dementia and depression. The resident had physician orders for PRN psychotropic medications, including quetiapine fumarate, prochlorperazine maleate, and hydroxyzine HCl, but there was no evidence in the medical record that the physician documented a rationale for extending the use of these medications beyond 14 days or evaluated the continued need for them since admission. A pharmacy review later recommended discontinuation of the PRN psychotropics due to non-use. Additionally, a staff member stated she was unaware of the 14-day limitation for PRN psychotropic medications and acknowledged that the orders had continued past the required timeframe without proper physician evaluation or documentation.
Failure to Assess and Supervise Residents for Smoking Safety
Penalty
Summary
The facility failed to assess and supervise residents for smoking safety as required by its own policies, resulting in deficiencies for two of three sampled residents. One resident, admitted with chronic obstructive pulmonary disease and deemed cognitively intact, was listed as an independent smoker but had no documented smoking assessment in the clinical record. This resident was observed disposing of a cigarette improperly and reported never being assessed or observed for smoking safety, despite being provided the facility's smoking policy only recently. Staff confirmed that, per policy, a smoking assessment should have been completed upon admission, but no evidence of such an assessment was found. Another resident, admitted with vascular dementia and care planned for supervised smoking, was found with cigarettes stored in their personal belongings rather than in the medication room as required. This resident was observed entering the smoking area independently, possessing smoking supplies, and smoking without staff supervision, with another resident lighting the cigarette. Staff interviews confirmed that the resident required supervision and that supplies should have been secured by staff, but these procedures were not followed. The lack of supervision and improper storage of smoking materials were acknowledged by facility staff.
Failure to Follow Physician's Orders for Oxygen Administration
Penalty
Summary
The facility failed to adhere to physician's orders regarding oxygen administration for five residents, leading to potential respiratory complications. Resident 13, diagnosed with chronic respiratory failure and heart failure, was observed receiving oxygen at 2 liters per minute instead of the prescribed 1 liter per minute. Similarly, Resident 15, with COPD and emphysema, was found to be on room air or receiving 1.5 liters per minute, contrary to the order for 2 liters per minute. Resident 16, who had acute respiratory failure and a transient cerebral ischemic attack, was receiving 1.5 liters per minute instead of the ordered 1 liter per minute, with staff failing to document the oxygen levels accurately. Resident 17, admitted with congestive heart failure and acute respiratory failure, was receiving oxygen at 2.5 liters per minute despite having no physician orders for oxygen. Lastly, Resident 19, with COPD and dysphagia, was administered oxygen at 1.5 liters per minute instead of the prescribed 2 liters per minute. In all cases, staff acknowledged the discrepancies between the physician's orders and the actual oxygen administration, indicating a systemic issue in following prescribed respiratory care protocols.
Failure to Provide Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure a resident received appropriate pressure ulcer treatments, resulting in the worsening of the resident's condition. Resident 4, who was admitted in 2017 with diagnoses including hypertension and diabetes, had a dressing on their right ankle dated 12/27/23. On that date, Staff 8, an LPN, measured the wound and provided the measurements to Staff 12, the former Director of Nursing Services (DNS). However, there was no follow-up notification to the physician, and no treatment orders were put in place for the pressure ulcer. By 1/3/24, during wound rounds with an outside wound care provider, it was discovered that the dressing was saturated, and the wound had deteriorated to a Stage 3 pressure ulcer, measuring 2 cm x 2.5 cm x 0.3 cm. Staff 12 acknowledged that no treatments were implemented from 12/27/23 through 1/3/24, and the wound care was not followed up on, leading to the worsening of the wound. The facility identified this as a deficiency in care provided to the resident.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received annual performance reviews, as evidenced by the lack of completed reviews for five randomly selected CNAs. These CNAs, identified as Staff 14, 18, 19, 20, and 21, were hired on various dates ranging from 2004 to 2021. Despite the expectation set by the Interim Administrator, Staff 2, that annual performance reviews should be conducted, none were completed for these staff members. This oversight was confirmed during a review of facility personnel records and an interview with Staff 2, who acknowledged the deficiency.
Inaccurate Daily Staff Postings
Penalty
Summary
The facility failed to ensure the accuracy of daily staff postings for 7 out of 30 days reviewed, which posed a risk to residents, the public, and staff due to the lack of accurate staffing information. The Direct Care Staff Daily reports, provided for the period from May 7, 2024, through June 10, 2024, revealed instances where portions of the forms were left blank or incomplete. Specifically, the incomplete information included the census, the number of staff working, and the number of hours worked. On June 14, 2024, during an interview, the Administrator and Corporate Consultant acknowledged the incompleteness of the reports for the specified days. The Administrator stated that it was her expectation that staff complete the daily staffing sheets at the beginning of each shift every day.
Failure to Maintain Medication Refrigerator Temperature Logs
Penalty
Summary
The facility failed to ensure appropriate medication storage temperatures were logged and maintained for a medication storage refrigerator. During an observation on June 13, 2024, it was noted that the temperature logs for the medication refrigerator were blank on multiple dates, including May 3, 10, 11, 12, 13, 18, 19, 20, 21, 26, 27, 28, 31, and June 1, 2, 3, 4, and 9, 2024. This oversight placed residents at risk for receiving medications with reduced efficacy. Staff 2, identified as the Director of Nursing Services (DNS), acknowledged the blank temperature logs and stated that the expectation was for the nurse to complete these logs.
Failure to Respect Resident's Dignity and Pain Management
Penalty
Summary
The facility failed to treat a resident with dignity and respect, as evidenced by an incident involving a Licensed Practical Nurse (LPN) who did not heed the resident's expressed pain during a routine care procedure. The resident, who was cognitively intact and had a history of shoulder pain, informed the LPN that lifting her arm caused significant discomfort. Despite this, the LPN continued with the procedure, which involved removing the resident's jacket, taking her blood pressure, and applying a lidocaine patch. This disregard for the resident's expressed pain and discomfort was documented in a facility investigation. The resident had previously communicated her shoulder pain to the staff, emphasizing her desire to avoid having her arm pulled. The LPN admitted to forgetting about the resident's shoulder pain and acknowledged being in a hurry during the incident. The resident's care plan, which advised staff to avoid rushing and to listen actively to the resident, was not followed. The Interim Administrator confirmed that the LPN did not slow down and failed to listen to the resident, which resulted in unnecessary pain for the resident.
Failure to Timely Provide SNF ABN Notice
Penalty
Summary
The facility failed to provide a written Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) in a timely manner for one resident reviewed for Beneficiary Protection Notification. The resident, who was admitted with diagnoses including metabolic encephalopathy and chronic obstructive pulmonary disease, was cognitively intact and responsible for their own decisions. The resident's last covered day of Medicare Part A services was on April 22, 2024, but the SNF ABN, Form CMS-10055, was not issued until June 11, 2024. This delay was confirmed by the Social Services Director, who acknowledged that the notice should have been provided on or before the last covered day. The facility administrator also stated that residents should be given a 48-hour notice of changes in coverage.
Delayed Incontinence Care for Two Residents
Penalty
Summary
The facility failed to provide timely incontinence care for two residents, leading to delayed assistance with personal hygiene. Resident 30, who was admitted with acute systolic heart failure and type two diabetes mellitus, was frequently incontinent and required extensive assistance for toileting. Despite using the call light to request incontinence care, Resident 30 experienced delays, with reports indicating a typical wait time of approximately two hours. Witnesses observed multiple CNAs entering the room without providing care, and the facility's administrator acknowledged awareness of complaints regarding long call light response times. Similarly, Resident 56, diagnosed with hepatic encephalopathy, required extensive assistance with toileting and bed mobility. On one occasion, after pressing the call light for assistance, Resident 56 waited over 90 minutes before receiving help, despite informing a CNA of the need for care. The CNA assigned to Resident 56 did not provide timely care due to confusion over room assignments. The interim administrator stated that resident care should be provided promptly, and staff should respond to all call lights regardless of room assignments.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Forest Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marquis Forest Grove Post Acute Rehab | 0.5 mi | ★★★★★ | 5 | 0 |
| Avamere Rehabilitation Of Hillsboro | 4.8 mi | ★★★★★ | 20 | 1 |
| Hillsboro Health & Rehabilitation Center | 5.9 mi | ★★★★★ | 3 | 0 |
| Maryville | 12.3 mi | ★★★★★ | 1 | 0 |
| Beaverton Post Acute Care Of Cascadia | 13.9 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.