Forest Grove Post Acute
3900 Pacific Avenue, Forest Grove, OR 97116 · Washington County · 114 certified beds · avg 82 residents/day · certified since Jul 11, 1983
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: ★★★★☆4/5 · CMS overall rating: 4/5
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)
▲ Immediate jeopardy, one-off · Jul 16, 2019 · F-0741
The facility did not have enough staff with the right skills to meet the mental and behavioral health needs of its residents, such as those living with dementia or depression.
Why it matters: Residents with dementia or other behavioral health needs may be mishandled, overmedicated, or left in distress.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Nov 29, 2018 (Past Non-Compliance)
▲ Actual harm, one-off · Jun 14, 2024 · F-0686 · triggered by a complaint
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: Jan 3, 2024 (Past Non-Compliance)
▲ Actual harm, one-off · Jul 16, 2019 · F-0658
The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Why it matters: Care that falls below professional standards can directly harm a resident's health and recovery.
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: Aug 29, 2019 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jul 16, 2019 · 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: Aug 29, 2019 (Deficient, Provider has date of correction)
All citations in the current public record (23)
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 11, 2026 | 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. · from a complaint |
| Jun 11, 2026 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint |
| Jul 25, 2025 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| Jul 25, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Dec 18, 2024 | E · Potential for harm, repeated | 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. · from a complaint |
| Jun 14, 2024 | ▲ 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. · from a complaint |
| Jun 14, 2024 | F · Potential for harm, facility-wide | The facility did not observe each nurse aide's job performance or provide regular training as required. · from a complaint |
| Jun 14, 2024 | E · Potential for harm, repeated | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. · from a complaint |
| Jun 14, 2024 | E · Potential for harm, repeated | 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 |
| Jun 14, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Jun 14, 2024 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. · from a complaint |
| Jun 14, 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. · from a complaint |
| Oct 6, 2023 | D · Potential for harm, one-off | The facility did not properly prepare residents for a safe transfer or discharge. Before a resident leaves, the facility must get them ready and make sure the move is safe and orderly. · from a complaint |
| Jul 16, 2019 | ▲ J · Immediate jeopardy, one-off | The facility did not have enough staff with the right skills to meet the mental and behavioral health needs of its residents, such as those living with dementia or depression. |
| Jul 16, 2019 | ▲ G · Actual harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Jul 16, 2019 | ▲ 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. |
| Jul 16, 2019 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jul 16, 2019 | F · Potential for harm, facility-wide | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. |
| Jul 16, 2019 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jul 16, 2019 | 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. |
| Jul 16, 2019 | 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. |
| Jul 16, 2019 | D · Potential for harm, one-off | The facility did not provide appropriate treatment and services to residents with a mental health condition, difficulty adjusting emotionally, or a history of trauma or post-traumatic stress disorder (PTSD). |
| Jul 16, 2019 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (7 → 2).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2019 | 10 | 3 | J ▲ |
| 2023 | 1 | 0 | D |
| 2024 | 8 | 1 | G ▲ |
| 2025 | 2 | 0 | D |
| 2026 | 2 | 0 | D |
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)
No fines or payment denials in the published 3-year window.
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) | 4.88 | 5.42 | 3.95 | bottom 22% in Oregon; top 15% in the U.S. |
| Registered Nurse hours | 0.34 | 0.78 | 0.69 | bottom 5% in Oregon; bottom 13% in the U.S. |
| Weekend total nurse staffing | 4.45 | 4.85 | 3.50 | bottom 26% in Oregon; top 13% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.23 | 0.48 | 0.48 | bottom 13% in Oregon; bottom 18% in the U.S. |
| Total nursing staff turnover (%) | 21.5 | 47.4 | 45.8 | top 2% in Oregon; top 4% in the U.S. |
| RN turnover (%) | 0.0 | 51.6 | 42.9 | — |
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 4.53, RN 0.31, weekend 4.13. 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: 2/5 · short-stay residents: 5/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Apt, Frederick | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/10/2024 |
| Jergensen, Joshua | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/10/2024 |
| Larson, David | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2024 |
| Larson, David | Individual | ADP of the SNF | NOT APPLICABLE | 07/11/2025 |
| Mitchell, John | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/10/2024 |
| Nhi-Reit of Idaho LP | Organization | ADP of the SNF | NOT APPLICABLE | 09/01/2024 |
| Providence Administrative Consulting Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 09/01/2024 |
| Roekel, Kayla | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2024 |
| Roekel, Kayla | Individual | ADP of the SNF | NOT APPLICABLE | 07/11/2025 |
| Truist Bank | Organization | 5% or Greater Security Interest | NOT APPLICABLE | 09/01/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What training does your staff have in dementia and behavioral health, and how many residents with these needs do you serve?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "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 |
|---|---|---|---|---|---|
| Marquis Forest Grove Post Acute Rehab | 0.5 mi | Forest Grove, OR | ★★★★★ | 4/5 | |
| Avamere Rehabilitation of Hillsboro | 4.8 mi | Hillsboro, OR | ★★★☆☆ | 2/5 | |
| Hillsboro Health and Rehabilitation | 5.9 mi | Hillsboro, OR | ★★★★☆ | 4/5 | |
| Maryville | 12.3 mi | Beaverton, OR | ★★★★☆ | 3/5 | |
| Beaverton Post Acute Care of Cascadia | 13.9 mi | Beaverton, OR | ★★★★★ | 4/5 | |
| Tigard Rehabilitation and Care | 15.7 mi | Tigard, OR | ★☆☆☆☆ | 1/5 | SFF |
| Chehalem Post Acute | 15.9 mi | Newberg, OR | ★☆☆☆☆ | 1/5 | |
| Avamere Rehabilitation of King City | 15.9 mi | Tigard, OR | ★★★★☆ | 3/5 | |
| Marquis Newberg | 16.5 mi | Newberg, OR | ★★★★★ | 5/5 | |
| Marquis Autumn Hills Memory Care | 16.6 mi | Portland, OR | ★★★★★ | 4/5 |
Compare this facility with the 3 closest →
All facilities in Forest Grove →
Facility data as of CMS processing date 2026-08-01. CCN 385155.