Marquis Mill Park
1475 SE 100th Avenue, Portland, OR 97216 · For profit - Corporation · 77 certified beds · (503) 262-6000 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (5/5)
- it has an abuse, neglect, or exploitation citation (F0602), cited Apr 2026
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $35,010 in federal fines (most recent 2026-04-24)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 27.3% | 14.9% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.5% | 4.7% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.4% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 3.6% | 2.0% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 4.9% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.8% | 2.4% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 9.1% | 20.6% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 0.0% | 12.4% | 18.9% | check this* — see note marked star below the table |
| Long-stay residents with pressure ulcers | 23.1% | 5.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 18.5% | 21.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 0.0% | 13.9% | 17.1% | check this* — see note marked star below the table |
| Short-stay residents who newly got an antipsychotic medication | 0.8% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 87.0% | 81.2% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 22.0% | 21.4% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 12.1% | 16.1% | 12.0% | typical |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
76.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 571 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 41.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 259 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.86 therapist hours per resident per day in 2026Q1 — more than 95% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 15% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 76.9%CMS range 72.6–80.0 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 8.8%CMS range 6.8–10.9 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 41.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 36.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 35.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.1% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 96.9% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.9% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.8% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.3%CMS range 3.5–7.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.90 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 77 beds and averages 63.3 residents a day — about 82% occupied, or roughly 14 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.19 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.50 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.67 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.52 hrs/resident/day on weekends vs 5.46 on weekdays — 17% thinner on weekends. RN hours go from 1.77 to 0.83 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 43% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
17 citations, most serious first. The 12 most serious are shown; the remaining 5 are one tap away and print in full.
- Immediate jeopardy · Kcited before2025-02-03 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to follow appropriate infection control practices during a COVID-19 outbreak for 2 of 4 halls reviewed for infection control. This deficient practice was determined to be an immediate jeopardy situation and placed residents at risk for contracting COVID-19. Findings include: The CDC's 3/6/24 Preventing Transmission of Viral Respiratory Pathogens in Healthcare Settings website, https://www.cdc.gov/infection-control/hcp/viral-respiratory-prevention/index.html, specified health care personnel are advised to apply appropriate Transmission-Based Precautions when providing care to a patient with known or suspected respiratory infection. Infection prevention and control practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection included to use Droplet Precautions with patients known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a patient who is…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2026-04-24 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review it was determined the facility failed to administer the correct medications for 1 of 3 sampled residents (#45) reviewed for hospitalizations. This failure resulted in Resident 45 experiencing decreased blood pressure and hospitalization. Findings include: The facility's Administering Medications policy revised 12/2025 included the following:- Medications shall be administered in a safe and timely manner, and as prescribed.- Medications must be administered in accordance with the orders.- The individual administering medications must verify the resident's identity before giving the resident her/his medications.- The individual administering the medication must check the label three times to verify the right medication, right dosage, right time and right method of administration before giving the medication.Resident 45 was admitted to facility in 4/2026 with diagnoses including encounter for surgical aftercare following surgery on the digestive system and essential hypertension (high blood pressure).The Admissions MDS with an ARD of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-04-24 · tag F0761 — failed to label and store drugs safely — patternEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview it was determined the facility failed to ensure medication and treatment carts were locked and secured appropriately for 1 of 4 halls observed (200 Hall) during random observations for medication and treatment cart storage. This placed residents at risk for unsafe access to stored medications. Findings include:The facility's Security of Medication Cart policy dated 5/2010 included the following:- The nurse must secure the medication cart during the medication pass to prevent unauthorized entry.- The cart must be locked before the nurse enters the resident's room.- Medication carts must be securely locked at all times when out of the nurse's view.On 4/20/26 at 2:40 PM, Staff 17 (RN) was observed alone standing next to an unlocked medication cart in the 200 Hall. At 2:42 PM, she walked away from the cart and out of the 200 Hall. At 2:42 PM, Staff 17 was observed locking the medication cart and stated the expectation was for medication carts to be locked whenever staff was away from it. Staff 17 stated she did not have the key to the medication cart,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-04-24 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review it was determined the facility failed to ensure hand hygiene was performed during wound care for 1 of 1 sampled resident (#7) reviewed for pressure ulcer. This placed residents at risk for cross contamination. Findings include: Resident 7 was admitted to the facility in 3/2026 with a diagnosis of diabetes. The facilities Standard Precautions policy and procedure last revised 5/2010 revealed hand hygiene (washing hands with soap and water or an alcohol-based hand rub), was to be performed when hands were not visibly soiled and gloves were to be changed, as necessary, during care of a resident to prevent cross-contamination when moving from a dirty site to a clean site. On 4/21/26 at 11:14 AM Staff 15 (LPN) was observed to remove Resident 7's old pressure ulcer dressing and adjusted Resident 7's incontinent brief. Staff 15 was stopped by this surveyor prior to him cleaning Resident 7's pressure ulcer. Staff 7 stated he should have changed gloves when going from a dirty task to a clean task. Staff 7 then removed her/his gloves and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-24 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review it was determined the facility failed to ensure residents were assessed to self-administer medications for 1 of 1 sampled residents (#9) reviewed for accident hazards. This placed resident at risk for unsafe medication administration. Findings include:The facility's Self-Administration of Drugs policy dated 5/2010 included the following:- Staff and practitioner will document their findings and the choices of residents who are potentially capable of self-administering medications.- Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents.- Staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for bedside storage.Resident 9 was admitted to facility in 5/2010 with diagnosis of end stage renal disease (permanent chronic kidney failure).The Quarterly MDS with an ARD of 3/7/26 revealed Resident 9 had a BIMS score of 14, which indicated the resident was cognitively intact.A review of Resident 9's clinical record revealed no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-24 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review it was determined the facility failed to ensure a resident's advance directive was filed in her/his clinical record for 1 of 1 sampled resident (#5) reviewed for advance directive. This placed residents at risk for end-of-life choices not being honored. Findings include: Resident 5 was admitted to the facility in 12/2025 with a diagnosis of cancer. Resident 5's 12/22/25 admission MDS revealed she/he was cognitively intact. Resident 5's 3/26/26 Multidisciplinary Care Conference revealed she/he and her/his family participated in the care conference. The care conference notes indicated Resident 5 had an advance directive and family was to provide a copy to the facility. Resident 5's clinical record revealed her/his advance directive was not filed. On 4/22/26 at 10:00 AM Resident 5 stated she/he had an advance directive. On 4/22/26 at 8:24 AM Staff 4 (Social Services) stated if a resident had an advance directive, she was to ensure family provided the advance directive to the facility. Staff 4 stated she did not follow-up with Resident 5's family. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-24 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review it was determined the facility failed to notify a resident representative after a change of condition for 1 of 1 resident (#87) reviewed for notifications. This placed residents at risk for uninformed healthcare decisions. Findings include:Resident 87 was admitted to the facility in 11/2024 with diagnoses including surgical treatment after a hip fracture, dementia, and anxiety disorder.A Resident Designation Form from 11/8/24 stated Resident 87 elected to have Witness 2 contacted in case of emergency.A Skilled Nursing Progress Note from Staff 21 (LPN) 12/3/24 revealed Resident 87 had the onset of a new possible infection at the surgical site of her/his left hip. Staff 23 (Nurse Practitioner) and Staff 22 (RNCM) were notified of this change of condition. Staff 23 directed Staff 21 to start Resident 87 on cephalexin, (an antibiotic).A 12/3/24 Physician Order directed cephalexin to be started on 12/3/25 to address Resident 87's suspected wound infection.Review of the 12/2025 MAR revealed Resident 87 started on an antibiotic, cephalexin, on the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-24 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to protect the resident's right to be free from misappropriation of property for 1 of 1 sampled resident (#86) reviewed for abuse. This placed residents at risk for continued depravation of goods and services. Findings include:Resident 86 admitted to the facility in 7/2025 with diagnoses including right femur fracture and major depressive disorder. The 7/31/25 admission MDS assessed Resident 86 as cognitively intact. The facility submitted a Facility Reported Incident (FRI) on 8/16/25 indicating Resident 86 received fraud alerts from her/his financial institutions and discovered two credit cards and one debit card missing. Resident 86 reported Staff 10 (Former Maintenance Assistant) had entered her/his room multiple times over the prior weeks without clear request, reportedly to check equipment. Interview with the resident's family and record review revealed fraudulent charges between 8/4/25 and 8/16/25 totaling over $1300, including a charge at a gas station in the same town where Staff 10 resided as well as miscellaneous…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-24 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review it was determined the facility failed to ensure the State Long-Term Care Ombudsman office was notified of a resident's discharge for 1 of 1 sampled resident (#85) reviewed for discharge. This placed residents at risk for lack of advocacy. Findings include: Resident 85 was admitted to the facility in 2/2026 with a diagnosis of respiratory failure. Resident 85's Clinical record revealed she/he was discharged in 2/2026. Resident 85's clinical record did not reveal the State Long-Term Care Ombudsman office was notified of her/his discharge. The facility's 1/1/26 through 3/31/26 Discharges list revealed Resident 85 was not listed as a discharged resident. On 4/23/26 at 8:58 AM Staff 6 (Business Office Manager) verified the 1/1/26 through 3/31/26 Discharge list did not include Resident 85, and this list was sent to the Ombudsman office to notify them of the facility discharged residents. On 4/24/26 at 8:57 AM Staff 1 (Administrator) stated a complete list of discharged residents were to be sent to the Ombudsman office.
- Potential for harm · D2026-04-24 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview, and record review it was determined the facility failed to ensure a resident's oxygen equipment was cleaned for 1 of 1 sampled resident (#5) reviewed for respiratory care. This placed residents at risk for decreased oxygen quality. Findings include: Resident 5 was admitted to the facility in 12/2025 with a diagnosis of a stroke. Resident 5's Task form for cleaning her/his oxygen filter indicated on 4/17/26 staff cleaned her/his oxygen filter. On 4/20/26 Resident 5's oxygen filter was observed with gray/brown dust coating the filter. On 4/22/26 at 8:11 AM Staff 7 (CNA) stated the nurses were responsible for cleaning the oxygen filters. On 4/22/26 at 8:19 AM Staff 21 (LPN) stated the oxygen company managed the oxygen equipment. On /22/26 at 11:44 AM Staff 8 (RNCM) verified Resident 5's oxygen filter was coated with dust and the amount of dust present likely did not build up after 4/17/26. On 4/24/26 at 9:15 AM Staff 2 (DNS) stated staff were to clean the oxygen filters weekly.
- Potential for harm · D2025-02-03 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to accurately code the MDS for 2 of 2 sampled residents (#s 6 and 65) reviewed for dental care and hospitalizations. This placed residents at risk for unmet care needs. Findings include: 1. The facility's 8/2017 Resident Assessment Instrument MDS 3.0 Policy indicated information derived from the comprehensive assessment enabled staff to plan care to allow the resident to reach her/his highest practicable level of functioning and included an assessment of the resident's dental status and the need for, and use of, dentures or other dental appliances. Resident 6 was admitted to the facility in 8/2024 with diagnoses including kidney failure. Resident 6's 8/5/24 Nursing admission Assessment indicated the resident had a full upper and lower set of dentures. Resident 6's 8/11/24 admission MDS revealed the resident was cognitively intact and not edentulous (without teeth). Resident 6's 8/24/24 Dental Care Plan indicated the resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-03 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review it was determined the facility failed to develop and implement a care plan related to the use of hearing aids for 1 of 1 sampled resident (#269) reviewed for hearing. This placed residents at risk for communication barriers and impaired hearing. Findings include: Resident 269 was admitted to the facility in 1/2025 with diagnoses including respiratory failure. In an interview on 1/27/25 at 10:26 AM, Witness 2 (Family Member) stated Resident 269 wore hearing aids during the day and needed assistance to charge them at night. Witness 2 stated when she/he visited the resident every morning the resident's hearing aids were still in her/his ears and were not charged. A review of Resident 269's care plan revealed no information related to use of hearing aids. On 1/28/25 at 8:43 AM, Resident 269 was observed sitting on her/his bed with one hearing aid in her/his left ear. The other hearing aid was in a charging device, located on the resident's nightstand. During an observation and interview with Resident 269 and Witness 2 on 1/29/25 at 10:21…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 5 citations
- Potential for harm · D2025-02-03 · tag F0687 — failed to care for feet properly — isolatedProvide appropriate foot care.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review it was determined the facility failed to provide appropriate foot care for 1 of 1 sampled resident (#6) reviewed for skin conditions. This placed residents at risk for lack of nail care and increased infections. Findings include: Resident 6 was admitted to the facility in 8/2024 with diagnoses including diabetes. Resident 6's 8/11/24 admission MDS revealed the resident was cognitively intact. Resident 6's 10/29/24 Physician Orders indicated the resident was to be seen by a podiatrist for onychomycosis (a fungal infection of the nails) and diabetic foot care. An 11/19/24 Social Services Note revealed a message was left with the podiatrist to get follow up regarding the scheduling of Resident 6's podiatry appointment. A 1/8/25 Physician Encounter Note completed by Staff 13 (Medical Director) indicated the resident had a referral to be seen by a podiatrist from 10/29/24. No evidence was found in Resident 6's clinical record to indicate additional efforts to schedule a podiatry appointment for the resident were made after 11/19/24. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-03 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review it was determined the facility failed to ensure a resident who was a trauma survivor received trauma-informed care for 1 of 1 sampled resident (#6) reviewed for PASARR (Pre-admission Screening and Resident Review). This placed residents at risk for re-traumatization and a decrease in their quality of life. Findings include: The facility's 5/2023 Trauma Informed Care Policy indicated the following: -Nursing staff, Social Services and the attending physician were to identify individuals with a history of trauma, as the resident was willing to disclose, as part of an initial assessment. Information could also be gathered from family and friends in order to identify and implement person-centered trauma-informed care. -Areas of potential life trauma were to be identified and developed into a person-centered care plan based on the Social Services admission Assessment. This Assessment was to gather how trauma impacted the resident's care needs and triggers in addition to the resident's treatment history and/or a specialist that may have…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-03 · tag F0742 — isolatedProvide 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review it was determined the facility failed to provide treatment and services to correct ongoing signs of depressive behavior for 1 of 1 sampled resident (#49) reviewed for behavioral-emotional needs. This placed residents at risk for unmet behavioral and emotional needs and a decrease in their quality of life. Findings include: The facility's undated Behavioral Assessment for Un-Met Needs/Psychoactive Medications Policy indicated the following: -A Behavior UDA (assessment) was to be opened by the Social Services Director at the time a new behavior was noted and completed by the interdisciplinary team to ensure environmental/facility practices or medical/clinical causes of behavior, non-pharmacological interventions implemented and delirium were ruled out before the initiation of a medication/increased dosing. -If the physician/NP initiated a psychoactive medication, the RNCM was to follow up with the prescriber regarding the continued use of the medication. If the medication was not discontinued, the Social Services Director was to open a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-03 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review it was determined the facility failed to ensure a medication administration error rate of less than 5%. There were two errors in 29 opportunities resulting in a 6.9% error rate. This placed residents at risk for reduced medication efficacy and adverse medication side effects. Findings include: The 2023 insulin lispro Kwikpen Manufacturer Instructions For Use and the 2022 How to Use Lantus Pen Manufacturer Instructions specified the following: - to prime pen, turn the Dose Knob to select two units. Hold the pen with the needles pointing up, tap the pen gently to collect air bubbles at the top, continue holding pen with needle pointing up, push the Dose Knob in until it stops and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. Turn the Dose Knob to select the number of units needed. Always perform these safety steps before each injection. Resident 118 was admitted to the facility in 1/2025 with diagnoses including type 2 diabetes mellitus (impaired insulin production). Resident 118's 1/2025 Physician Orders…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-08-25 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
1. Based on observation, interview and record review it was determined the facility failed to ensure adequate hand hygiene during medication administration for 3 of 9 sampled residents (#s 33, 41 and 161) reviewed during medication administration. This placed residents at risk for spread of infection. Findings include: The facility's 5/2020 Handwashing/Hand Hygiene Policy & Procedure specified hand hygiene was the primary means to prevent the spread of infection. Employees must perform hand hygiene before and after direct contact with a resident or their immediate environment. On 8/24/23 at 2:26 PM Staff 3 (LPN) dispensed and administered Resident 41's medication in the resident's room. Staff 3 did not perform hand hygiene before or after she dispensed and administered the medication. On 8/24/23 at 2:36 PM Staff 3 dispensed and administered Resident 33's medications in the resident's room. Staff 3 did not perform hand hygiene before or after she dispensed and administered the medication. On 8/24/23 at 2:44 PM Staff 3 dispensed and administered Resident 161's medications in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$35,010 in federal fines across 2 penalties.
- $17,665 — penalty dated 2026-04-24
- $17,345 — penalty dated 2025-02-03
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to MARQUIS COMPANIES — 15 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 4.3 | -1.3 vs chain |
| Health inspection | 2 of 5 | 3.8 | -1.8 vs chain |
| Staffing | 5 of 5 | 4.4 | +0.6 vs chain |
| Quality measures | 3 of 5 | 3.2 | -0.2 vs chain |
The other 14 homes this chain runs (chain average 4.3★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| MARQUIS COMPANIES I, INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 03/01/1994 |
| FOGG, PHILLIP | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER | NO PERCENTAGE PROVIDED | since 03/01/1994 |
| BUCHER, AMY | Individual | W-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2007 |
| FOGG, STEVEN | Individual | W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 10/01/2001 |
| HAGEN, JENNIFER | Individual | W-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL | — | since 09/24/2007 |
| TONE, STACI | Individual | W-2 MANAGING EMPLOYEE | — | since 03/01/1994 |
CMS files one row per role, so the 12 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $669K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OR
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Oregon Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 385214. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-24, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.