Your report for Holladay Park Plaza
Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- OregonAbove 81% of peers127 rated homes · average 3.0★
- Multnomah CountyAbove 78% of peers33 rated homes · average 2.9★
- United StatesAbove 80% of peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point5★+2.2 vs OR avg
- StaffingCan add or remove a star5★+1.3 vs OR avg
- Quality measuresCan add or remove a star5★+1.5 vs OR avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles5★Above 88% of peersOR avg2.8★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover5★Above 82% of peersOR avg3.7★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments5★Above 82% of peersOR avg3.5★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff5.48hrsAbove 81% of peersOR avg4.95Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only1.12hrsTop 6%OR avg0.68Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better34%Above 86% of peersOR avg49%RN turnover29%
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$0Above 56% of peersOR avg$32,647Fines · denials0 · 0
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthMar 2023 – Sep 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Sep 5, 2025Cycle 1worst D · no actual harm
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Oct 10, 2025
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Oct 10, 2025
Jun 13, 2024Cycle 2worst D · no actual harm
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Jul 24, 2024
- Notify the resident or the residentâs representative in writing how long the nursing home will hold the residentâs bed in cases of transfer to a hospital or therapeutic leave.Resident RightsD · isolatedCorrected Jul 24, 2024
Mar 13, 2023Cycle 3worst D · no actual harm
- F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Apr 26, 2023
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Apr 26, 2023
- F679Provide activities to meet all resident's needs.Quality of Life and CareD · isolatedCorrected Apr 26, 2023
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Apr 26, 2023
- F688Provide 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.Quality of Life and CareD · isolatedCorrected Apr 26, 2023
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Apr 26, 2023
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Apr 26, 2023
- F742Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.Quality of Life and CareD · isolatedCorrected Apr 26, 2023
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Apr 26, 2023
- F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlD · isolatedCorrected Apr 26, 2023
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Apr 26, 2023
- F583Keep residents' personal and medical records private and confidential.Resident RightsD · isolatedCorrected Apr 26, 2023
- F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Resident RightsD · isolatedCorrected Apr 26, 2023
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined5.48hrs
- Registered nursesRN hours only1.12hrs
- Licensed practical nursesLPN hours0.48hrs
- Nurse aidesCNA hours3.88hrs
- Weekend nursingAll staff on Saturdays and Sundays4.92hrs
- Oregon average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better34%Above 86% of peersOR avg 49%
- RN turnoverRegistered nurses only29%Not ranked by CMS
- Administrators who leftIn the past year2Leadership changed
- Occupancy51 certified beds · ~31 residents a day61%Above only 35% of peersOR avg 69%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $0In fines
- 0Fines
- 0Payment denials
- $32,647OR avg in fines
Actions on record
Ownership
As filed with CMSStructure
- Ownership type
- Non profit - Corporation
- Chain
- Pacific Retirement Services10 facilities in the chain4.7★ chain average
- Certification
- Medicare
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
- Pacific Retirement Services INC
- Michael Ellis
- Thomas Fuller
- Lynn Johnson
- Kathleen McLaughlin
- Michelle Neal
- Eric Sholty
- Susan Platte
- Mufg Union Bank Na
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 385259 · 1300 NE 16TH AVENUE, PORTLAND, OR, 97232.
- Percentiles compare this facility with every rated nursing home in Oregon and Multnomah County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.









