Cottage Grove Post Acute
515 Grant Street, Cottage Grove, OR 97424 · Lane County · 80 certified beds · avg 66 residents/day · certified since Jun 22, 1982
Part of chain: PACS GROUP (274 facilities, chain avg rating 2.9★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Jun 27, 2025 · F-0697 · triggered by a complaint
The facility did not provide safe and appropriate pain management for a resident who needed it.
Why it matters: Untreated pain causes needless suffering and can lead to depression, poor sleep, and declining health.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 23, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Nov 18, 2022 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Dec 29, 2022 (Deficient, Provider has date of correction)
All citations in the current public record (26)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 27, 2025 | ▲ G · Actual harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint |
| Jun 27, 2025 | E · Potential for harm, repeated | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. |
| Jun 27, 2025 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Jun 27, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jun 27, 2025 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Jun 27, 2025 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Jun 27, 2025 | D · Potential for harm, one-off | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). |
| Jun 27, 2025 | D · Potential for harm, one-off | The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way. |
| Jun 27, 2025 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Jun 27, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Oct 16, 2024 | D · Potential for harm, one-off | The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint |
| Oct 16, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Mar 8, 2024 | F · Potential for harm, facility-wide | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. |
| Mar 8, 2024 | E · Potential for harm, repeated | The facility did not observe each nurse aide's job performance or provide regular training as required. |
| Mar 8, 2024 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Mar 8, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Mar 8, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Mar 8, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Nov 18, 2022 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Nov 18, 2022 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Nov 18, 2022 | E · Potential for harm, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Nov 18, 2022 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Nov 18, 2022 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Nov 18, 2022 | E · Potential for harm, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Nov 18, 2022 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Nov 18, 2022 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (6 → 10).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 8 | 1 | G ▲ |
| 2024 | 8 | 0 | F |
| 2025 | 10 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $20,670.
| Date | Type | Amount / length |
|---|---|---|
| Jun 27, 2025 | Fine | $20,670 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Oregon avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 5.12 | 5.42 | 3.95 | bottom 31% in Oregon; top 11% in the U.S. |
| Registered Nurse hours | 0.42 | 0.78 | 0.69 | bottom 10% in Oregon; bottom 26% in the U.S. |
| Weekend total nurse staffing | 4.51 | 4.85 | 3.50 | bottom 33% in Oregon; top 12% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.20 | 0.48 | 0.48 | bottom 6% in Oregon; bottom 12% in the U.S. |
| Total nursing staff turnover (%) | 47.0 | 47.4 | 45.8 | bottom 48% in Oregon; bottom 44% in the U.S. |
| RN turnover (%) | 66.7 | 51.6 | 42.9 | bottom 30% in Oregon; bottom 15% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.64, RN 0.38, weekend 4.09. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 5/5 · short-stay residents: 3/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Apt, Frederick | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/10/2024 |
| Barr, Jennifer | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2024 |
| Barr, Jennifer | Individual | ADP of the SNF | NOT APPLICABLE | 05/29/2025 |
| Cottage Grove 515 Realty LLC | Organization | ADP of the SNF | NOT APPLICABLE | 09/01/2024 |
| Jergensen, Joshua | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/10/2024 |
| Mitchell, John | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/10/2024 |
| Pompey, Karen | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/21/2024 |
| Providence Administrative Consulting Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 09/01/2024 |
| Truist Bank | Organization | 5% or Greater Security Interest | NOT APPLICABLE | 09/01/2024 |
| Wallenkampf, Victor | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2024 |
| Wallenkampf, Victor | Individual | ADP of the SNF | NOT APPLICABLE | 05/29/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "How soon after admission is a full assessment completed, and how are the findings shared with the family?"
- "Could I join residents for a meal to see the food quality and temperature for myself?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Creswell Post Acute | 9.2 mi | Creswell, OR | ★★☆☆☆ | 2/5 | |
| Creekside Health and Rehabilitation of Cascadia | 16.4 mi | Eugene, OR | ★★★★★ | 4/5 | |
| Cascade Manor | 16.8 mi | Eugene, OR | ★★★★☆ | 4/5 | |
| South Hills Rehabilitation Center | 16.9 mi | Eugene, OR | ★☆☆☆☆ | 1/5 | abuseSFF |
| Hillside Heights Rehabilitation Center | 17.0 mi | Eugene, OR | ★★★☆☆ | 3/5 | |
| Avamere Rehabilitation of Eugene | 17.6 mi | Eugene, OR | ★☆☆☆☆ | 1/5 | |
| Valley West Health Care Center | 17.7 mi | Eugene, OR | ★★☆☆☆ | 2/5 | |
| Marquis Springfield | 19.3 mi | Springfield, OR | ★★★★☆ | 3/5 |
Compare this facility with the 3 closest →
All facilities in Cottage Grove →
Facility data as of CMS processing date 2026-08-01. CCN 385152.