Cottage Grove Post Acute
515 Grant Street · Cottage Grove, OR · 97424 · 5419425528
80 certified beds For profit - Corporation Chain: Pacs Group
Why this verdict
- Inspection results are getting worse cycle over cycle, not better.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
Cited under the freedom-from-abuse rule
Cited 1 time under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 3 of 5 Inspections: 3 of 5 Staffing: 3 of 5 Quality measures: 4 of 5
| Total nurse hours / resident-day | 4.31 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.33 | 0.55–0.75 |
| Weekend hours / resident-day | 3.86 | ≈ weekday level |
| Nursing turnover / year | 49% | median 45% |
| Fines (3-yr window) | 1 · $20,670 |
Inspection citations (26 in the current record)
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Actual harm · G June 27, 2025 · found via complaint
Provide safe, appropriate pain management for a resident who requires such services.
Corrected July 23, 2025 · Quality of Life and Care
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Potential for harm · D June 27, 2025
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected July 23, 2025 · Resident Rights
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Potential for harm · D June 27, 2025
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 July 22, 2025 · Resident Rights
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Potential for harm · D June 27, 2025
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected July 23, 2025 · Resident Rights
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Potential for harm · E June 27, 2025
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected July 23, 2025 · Resident Assessment and Care Planning
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Potential for harm · D June 27, 2025
Assess the resident when there is a significant change in condition
Corrected July 23, 2025 · Resident Assessment and Care Planning
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Potential for harm · D June 27, 2025
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected July 23, 2025 · Resident Assessment and Care Planning
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Potential for harm · D June 27, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected July 23, 2025 · Quality of Life and Care
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Potential for harm · E June 27, 2025
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected July 23, 2025 · Nutrition and Dietary
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Potential for harm · E June 27, 2025
Provide and implement an infection prevention and control program.
Corrected July 23, 2025 · Infection Control
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Potential for harm · D October 16, 2024 · found via complaint
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected October 2, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D October 16, 2024 · found via complaint
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 October 2, 2024 · Pharmacy Service
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Potential for harm · D March 8, 2024
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected April 1, 2024 · Resident Assessment and Care Planning
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Potential for harm · D March 8, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected April 1, 2024 · Quality of Life and Care
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Potential for harm · D March 8, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected April 1, 2024 · Quality of Life and Care
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Potential for harm · D March 8, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Corrected April 1, 2024 · Quality of Life and Care
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Potential for harm · E March 8, 2024
Observe each nurse aide's job performance and give regular training.
Corrected April 1, 2024 · Nursing and Physician Services
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Potential for harm · F March 8, 2024
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected April 1, 2024 · Nutrition and Dietary
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Actual harm · G November 18, 2022
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected December 29, 2022 · Quality of Life and Care
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Potential for harm · E November 18, 2022
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 December 29, 2022 · Resident Rights
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Potential for harm · E November 18, 2022
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected December 29, 2022 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E November 18, 2022
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected December 29, 2022 · Resident Assessment and Care Planning
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Potential for harm · D November 18, 2022
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected December 29, 2022 · Quality of Life and Care
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Potential for harm · D November 18, 2022
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected December 29, 2022 · Quality of Life and Care
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Potential for harm · E November 18, 2022
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected December 29, 2022 · Pharmacy Service
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| June 27, 2025 | Fine | $20,670 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 385152 · certified since June 22, 1982. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.