Marquis Piedmont Post Acute Rehab
319 NE Russet, Portland, OR 97211 · For profit - Corporation · 70 certified beds · (503) 289-5571 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Apr 2026
- a high number of inspection citations overall (18) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (60%) runs well above the national median (45%)
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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
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 | 2 of 5 |
| Long-stay residentspeople who live here | 2 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 held steady at 4 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 | 18.6% | 14.9% | 15.4% | worse |
| Long-stay residents who lose too much weight | 7.5% | 4.7% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.5% | 1.4% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 3.2% | 2.0% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 3.5% | 4.9% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.6% | 2.4% | 3.3% | better |
| Long-stay residents on antianxiety or hypnotic medication | 18.3% | 12.4% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 10.4% | 5.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 28.4% | 21.8% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 20.2% | 13.9% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.3% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 88.7% | 81.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 25.4% | 21.4% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 14.2% | 16.1% | 12.0% | worse |
§ 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.
57.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 138 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 53.6% 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 56 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 0.30 therapist hours per resident per day in 2026Q1 — more than 49% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 7% 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 | 57.6%CMS range 50.0–67.2 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.0%CMS range 6.3–12.5 | 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 | 53.6% | 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 | 53.6% | 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 | 48.2% | 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 | 97.5% | 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 | 97.9% | 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 | 100.0% | 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 | 0.0% | 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 | 5.1% | 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 | 6.6%CMS range 3.9–11.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.84 | 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 70 beds and averages 46.9 residents a day — about 67% occupied, or roughly 23 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 6.20 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.94 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.85 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 5.54 hrs/resident/day on weekends vs 6.47 on weekdays — 14% thinner on weekends. RN hours go from 1.14 to 0.44 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 60% is well above the national median of 45%.
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.
18 citations, most serious first. The 10 most serious are shown; the remaining 8 are one tap away and print in full.
- Potential for harm · E2026-04-10 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to ensure medications and biologicals were secured for 2 of 3 medication carts and 2 of 3 treatment carts reviewed for safe medication storage. This placed residents at risk for unauthorized access to medications. Findings include:The facility's 5/2010 Security of Medication Cart Policy specified the following: -The nurse must secure the medication cart during the medication hall to prevent unauthorized entry. -Medication carts must be securely locked at all times when out of the nurse's view. 1. On 4/6/26 at 12:02 PM a treatment cart was observed to be unlocked on the North Hall. The nurse was not in view of the cart. The treatment cart contained multiple drawers with resident care items, including insulin and insulin supplies, prescribed creams and lotions, wound care supplies, nebulizer medications and supplies, and shampoos and other treatment supplies. On 4/6/26 at 12:04 PM Staff 10 (LPN) confirmed the cart was unlocked…
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 · D2026-04-10 · 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 assess residents for safe self-administration of medication for 1 of 2 sampled residents (# 29) reviewed for self-administering medication. This placed residents at risk for an unsafe medication regimen. Findings include:Resident 29 was admitted to the facility in 12/2025 with diagnoses including depression and end stage renal failure. Resident 29's 12/17/25 admission MDS assessed her/him as cognitively intact. On 4/6/26 at 11:47 AM and 1:19 PM observations were made of an empty six pack of Imodium on Resident 29's dresser to the right of her/his bed. On 4/6/26 at 2:34 PM observations were made of an empty six pack of Imodium on Resident 29's dresser to the right of her/his bed and a small clear plastic pill cup which contained two capsule pills and three small tablet pills on her/his window counter. On 4/7/26 at 1:50 PM observation was made of an empty six pack of Imodium on Resident 29's dresser to the right of her/his bed. On 4/8/26 at 8:39 AM three individual empty pill packs were observed…
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 · D2026-04-10 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to protect the resident's right to be free from physical abuse for 1 of 1 (#11) sampled resident reviewed for abuse. This placed residents at risk for continued physical abuse. Findings include: Resident 11 was admitted to the facility in 2024 with diagnoses including dementia and hearing deficit.Resident 11's 10/9/25 Quarterly MDS assessed her/him as cognitively intact and received anticoagulant (blood thinner) medication daily.Resident 36 admitted to the facility in 11/2025 with diagnoses including diabetes and visual deficit.Resident 36's 11/30/25 admission MDS assessed her/him as cognitively intact.On 3/29/26 Staff 21 (LPN) initiated a Resident-to-Resident Event Assessment for an incident involving Resident 11 and Resident 36. The assessment revealed Resident 11 reported asking Resident 36 to turn down the television volume and was punched in the face on 3/29/26 at 7:50 PM, resulting in Resident 11 obtaining a bloody nose. Staff 21 cleaned up Resident 11's face, assessed her/him for injury and found 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 · D2026-04-10 · 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 — an excerpt from the official record, may be distressing
Based on interview and record review it was determined the facility failed to provide notice of bed hold policies for 1 of 1 sampled resident (#4) reviewed for hospitalizations. This placed residents at risk for miscommunication of the discharge process. Findings include:Resident 4 was admitted to the facility in 2/2026 with diagnoses of congestive heart failure and epididymitis (inflammation of the tube at the back of the testicle). Resident 4's clinical record revealed the resident was transferred to the hospital on 4/3/26 for evaluation and treatment related to swelling of the scrotum. The resident's provider was notified, and orders were received to send Resident 4 to the hospital for further evaluation. Resident 4's clinical record did not contain documentation to indicate a written notice of the facility's bed hold policy was provided to Resident 4 or her/his representative. On 4/10/26 at 11:30 AM, Staff 2 (DNS) stated the charge nurse was responsible for providing the bed hold policy to residents when they were sent to the hospital. Staff 2 stated there was no documentation…
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 · Dcited before2026-04-10 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure nail care was provided for 1 of 5 sampled residents (#29) reviewed for ADLs. This placed residents at risk for unkept hygiene needs. Findings include: Resident 29 admitted to the facility in 12/2025 with diagnoses including diabetes and end stage renal failure.Resident 29's 12/17/25 admission MDS assessed her/him as cognitively intact.On 4/6/26 at 11:47 AM Resident 29 was observed with long pointed fingernails with dark substance under the nails. Resident 29 stated she/he required assistance to trim her/his fingernails due to her/his diabetes diagnosis. Resident 29 stated she/he would like her/his nails trimmed and had not been offered assistance.Record review of Resident 29's health record revealed no directions for staff to assist or offer to trim her/his fingernails and no documentation the fingernails had been completed.On 4/8/26 at 2:27 PM Staff 13 (CNA) stated he did not trim resident's fingernails if the resident was diabetic and only licensed nurses completed the task.On 4/8/26 at 2:29 PM Staff…
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 · D2026-04-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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 care planned safety interventions for 1 of 7 sampled residents (#25) reviewed for accidents. This placed residents at risk for falls and injury. Findings include:Resident 25 was admitted to the facility in 8/2024 with diagnoses of dementia and anxiety disorder. A 3/16/26 Quarterly MDS revealed Resident 25 had a BIMS of 14, which indicated she/he was cognitively intact. A 3/27/26 fall care plan revealed Resident 25 was at high risk for falls due to acute medical conditions, stroke and history of falls. Fall preventions included no assistive devices at bedside, bed in lowest position and fall mat at bedside. Random observations from 4/6/26 through 4/9/26 from 8:00 AM to 4:00 PM revealed Resident 25 was observed in bed with her/his walker at bedside and within reach, the bed was not in the lowest position (approximately knee height), and no fall mat was in place.On 4/9/26 at 10:18 AM, Staff 17 (CNA) stated Resident 25 was a high fall risk and was to have no assistive devices at bedside,…
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 · D2026-04-10 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to identify PTSD (Post Traumatic Stress Disorder) triggers, provide treatment and services to address distress related to PTSD for 1 of 1 sampled resident (#5) reviewed for behavior health. This placed residents at risk for unrecognized triggers and increased or worsening PTSD related symptoms. Findings include:A 5/2019 Trauma Informed Care Policy indicated staff completed assessments to gather how trauma impacts the residents care needs in triggers, approaches and person-centered care planning, duration and frequency of problematic behaviors or changes in behavior, cognition, or mood. Resident 5 was admitted to the facility on [DATE] with diagnoses including PTSD. A 3/23/26 admission MDS indicated Resident 5 had a BIMS score of 15 indicating the resident was cognitively intact. The Mood and Behavior CAA indicated the resident's psychosocial well-being would be addressed in her/his care plan with a goal of maintaining current…
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 · D2026-04-10 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
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 provide dental services for 1 of 2 sampled residents (#9) reviewed for dental care needs. This placed residents at risk for inadequate provision of dental services. Findings include: Resident 9 was admitted to the facility in 3/2026 with diagnoses including end stage renal disease and type 2 diabetes.Resident 9's admission MDS dated [DATE] revealed she/he was cognitively intact and had no missing, cracked or decayed teeth.Resident 9's 3/12/26 Nursing admission Assessment indicated she/he had, no dental issues.Resident 9's care plan dated 3/16/26 indicated she/he required constant supervision and physical assistance to complete oral hygiene tasks.On 4/6/26 at 2:33 PM, Resident 9 was observed to have several broken and missing upper front teeth. Resident 9 stated she/he was missing most of her/his upper teeth and had cavities which made it challenging and sometimes painful to chew. Resident 9 stated staff never examined 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 · D2024-12-06 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 care plans were revised to accurately reflect the needs of residents for 1 of 4 sampled residents (#37) reviewed for nutrition and positioning. This placed residents at risk for receiving unneeded assistance. Findings include: Resident 37 was admitted to the facility in 5/2024 with diagnoses including stroke and a stage 4 pressure injury (a full thickness tissue loss with exposed bone, tendon or muscle). Resident 37's nutrition care plan, dated 5/3/24, and Restorative care plan, dated 6/3/24, indicated Resident 37 was at risk for nutritional deficits such as weight loss and decline in ROM to her/his hand. Interventions included: -1:1 total assistance for all meals and snacks. - Adaptive equipment was to be used including adaptive silverware, scoop plate, and an adaptive cup or coffee cup. - Staff were to put a splint in place in the resident's hand during the day for four hours, and at night, and were to to thoroughly wash and dry the resident's skin before splint application 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 · D2024-12-06 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 enhanced barrier precautions (EBP) were followed for 1 of 1 resident (#37) reviewed for EBP. This placed residents at risk for exposure to infections. Findings include: The facility's undated Isolation - Categories of Transmission-Based Precautions policy indicated EBP were to be used for residents with catheters and complex wounds. The precautions included use of gloves and gowns while providing high contact care such as transfers, wound care, peri-care, and dressing assistance. Resident 37 was admitted to the facility in 5/2024 with diagnoses including stroke and stage 4 pressure injury (a complex wound). Resident 37's 5/3/24 care plan indicated she/he was at risk for infection due to a stage 4 pressure injury. Interventions included EBP. On 12/3/24 at 11:56 AM an observation of Resident 37's care revealed Staff 9 (CNA) and Staff 8 (NA) provided transfer assistance and personal hygiene without donning gowns. On 12/3/24 at 12:05 PM Staff 8 (NA) was unable to explain what EBP was…
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 8 citations
- Potential for harm · F2024-09-30 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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 there were sufficient nursing staff available to provide the necessary care and services to meet residents' needs in 1 of 1 facility reviewed for staffing. This placed residents at risk for unmet care needs. Findings include: On 9/24/24 the facility had a census of 51 residents. On 9/26/24, Staff 1 (Administrator) provided a list of residents who: -Required two-person mechanical lift transfers: 17; -Required two-person extensive or total assistance for bathing: 3; -Required two-person extensive or total assistance for toileting: 3; -Required two-person extensive or total assistance for dressing: 6; -Required one-to-one feeding: 3 -Had behavioral health needs which required monitoring: 50; -Were high fall risks: 28; -Were considered at risk for elopement: 1 and -Required bariatric care (body mass index greater than 40): 6. On 8/26/24 a public complaint was received by the State Agency which alleged staff were not able to provide care such as showers and care was not timely due to low…
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 · E2024-09-30 · tag F0732 — patternPost nurse staffing information every day.
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 Direct Care Staff Daily Report (DCSDR) postings were thoroughly completed or accurately reflected the number of staff working and their hours worked for 37 of 37 days reviewed for sufficient staffing. This placed residents at risk for incorrect staffing information. Findings include: Review of the 8/18/24 through 9/24/24 DCSDRs indicated the staff postings were incomplete or inaccurate on all 37 days reviewed. On 9/25/24 at 8:24 AM Staff 2 (DNS) acknowledged the 8/18/24 through 9/24/24 DCSDRs were not accurately completed and did not include the hours staff members worked on all 37 days reviewed.
- Potential for harm · D2024-09-30 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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 treat residents in a dignified manner for 1 of 3 residents reviewed for resident rights. This placed residents at risk for diminished quality of life. Findings include: This deficient practice was identified at past non-compliance in the area of 483.10 Resident Rights when the facility failed to provide an environment which promoted the maintenance of dignity and respect for residents' quality of life. On 2/20/24, the non-compliance was corrected when the facility completed a root cause analysis of the incident and determined Staff 19 treated residents in a manner which was undignified and disrespectful. The Plan of Correction included: 1. All staff were educated on resident rights, respect, dignity, abuse and neglect. 2. All staff completed written tests on their knowledge of resident rights from the education provided. 3. Dignity and respect audits were completed on residents. 4. The quality assurance committee reviewed…
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 · Dcited before2024-09-30 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
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 dependent residents received showers for 1 of 2 sampled residents (#17) reviewed for showers. This placed residents at risk for unmet needs and loss of dignity. Findings include: Resident 17 was admitted to the facility in 5/2024 with diagnoses including multiple sclerosis (a progressive neurological disorder) and morbid obesity (having a body mass index greater than 40). Resident 17's 9/6/24 Quarterly MDS indicated the resident had no cognitive impairment and was dependent for bathing/showering. The facility's 8/2024 shower schedule revealed Resident 17 was to receive showers twice a week, on Sundays and Thursdays. Resident 17's 8/2/24 through 8/31/24 bathing task logs indicated the resident received bathing on the following days: - 8/2, 8/9, 8/21, 8/28 and 8/31. Resident 17 received five out of nine scheduled showers. A review of Resident 17's Progress Notes from 8/1/24 through 8/31/24 revealed no documentation Resident 17 was provided with additional bathing opportunities when bathing was not…
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 · F2020-03-02 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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 proper hand hygiene in 1 of 1 dining rooms and failed to store food in a sanitary manner in 1 of 2 unit refrigerators. This placed the residents at risk for contamination and foodborne illness. Findings include: 1. Review of the facility's 1/2018 Handwashing Policy revealed staff were to wash their hands after sneezing, facial touching, contact with contaminated objects, when changing tasks or doing activities that contaminate the hands. On 2/24/20 at 12:21 PM Staff 16 (Diet Aide) picked up a walkie talkie, scratched his forehead and continued prepping beverages without washing his hands. On 2/26/20 at 11:58 AM Staff 14 (Prep Server) sneezed while at the steam table, donned gloves and began plating food without washing her hands. On 2/26/20 at 12:02 PM Staff 15 (Diet Aide) rubbed his nose gloveless and continued prepping beverages without washing his hands. In an interview on 2/26/20 at 12:34 PM Staff 16 stated handwashing should be done after touching his face or dirty objects like 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 · D2020-03-02 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 implement care plan interventions in the area of falls for 1 of 2 sampled residents (#22) who were reviewed for falls. This placed residents at risk for falls. Findings include: Resident 22 was admitted to the facility in 3/2019 with diagnoses including stroke and difficulty walking. The Comprehensive Care Plan included the following toileting interventions: - Do not leave unattended in bathroom, - Constant supervision and physical assist for safety. The 5/31/19 Post Fall Assessment indicated on 5/28/19 Resident 22 was in the bathroom, the CNA left the room for several minutes and Resident 22 fell during the CNA's absence. In an interview on 2/25/20 at 10:35 AM, Witness 1 (Complainant) stated Resident 22 had been care planned for supervision at all times when toileting and on 5/28/19 the CNA left Resident 22 unattended in the bathroom which resulted in her/his fall. In an interview on 2/26/20 at 4:47 PM, Staff 4 (LPN Resident Care Manager) stated on 5/28/19 a CNA assisted Resident 22 to the bathroom with 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 · D2020-03-02 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 PRN psychotropic medications were limited to 14 days without a documented clinical rationale for continued use for 1 of 5 sampled residents (#10) whose medications were reviewed. This placed residents at risk for unnecessary psychotropic medications and potential adverse side effects. Findings include. Resident 10 was admitted to the facility in 9/2019 with diagnoses including vascular dementia with behavior disturbance. Resident 10's 11/25/19 Quarterly MDS indicated the resident received an anti-anxiety psychotropic medication. Resident 10's 3/2020 signed physician orders included clonazepam 0.5 mg by mouth every eight hours PRN for anxiety. Review of Resident 10's MARs revealed the resident received clonazepam 0.5 mg PRN on the following days: -10/2019: 6th, 9th, 10th, 15th, 16th, 21st, 22nd. -11/2019: 4th, 10th, 20th, 25th. -12/2019: 4th, 6th, 15th, 22nd, 29th, and 31st. -1/2020: 5th, 10th, 15th. -2/2020: 7th, 19th, and 23rd. On 3/2/20 at 10:51 AM Staff 17 (RNCM) stated Resident 10 should be…
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 · D2020-03-02 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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 document follow up for physician recommendations for 1 of 3 sampled residents (#6) reviewed for pressure ulcers. This placed residents at risk for an incomplete medical record. Findings include: Resident 6 was admitted to the facility in 2/2019 with diagnoses including dementia and a pressure ulcer. A 1/14/20 physician note revealed a recommendation for a bowel program to keep stool out of the resident's wound bed. Resident 6's 1/14/20 through 3/2/20 medical records contained no documented response to the physician's recommendation. On 3/2/20 at 3:06 PM Staff 7 (RNCM) stated she spoke with the resident's representatives to ensure a scheduled bowel program was something the family wished to implement due to the resident's high rate of refusal for cares, unwillingness to get out of bed and increased agitation when attempting cares. Staff 7 stated she did not document the conversation with the family representatives but should have. On 3/2/20 at 3:30 PM Staff 2 (DNS) stated she expected staff to document when…
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
No federal fines in the current CMS record.
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 | 4 of 5 | 4.3 | -0.3 vs chain |
| Health inspection | 4 of 5 | 3.8 | +0.2 vs chain |
| Staffing | 4 of 5 | 4.4 | -0.4 vs chain |
| Quality measures | 2 of 5 | 3.2 | -1.2 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; OPERATIONAL/MANAGERIAL CONTROL | 100% | since 04/01/2013 |
| FOGG, PHILLIP | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | 100% | since 06/22/2012 |
| ENGLISH, MEAGAN | Individual | CONTRACTED MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2013 |
| FOGG, STEVEN | Individual | CONTRACTED MANAGING EMPLOYEE; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2013 |
| LEVEE, KATHLEEN | Individual | CONTRACTED MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2013 |
| TONE, STACI | Individual | CONTRACTED MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2013 |
| OHMART, TERESA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2013 |
CMS files one row per role, so the 14 rows in the source record cover these 7 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 $892K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
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 385208. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-10, 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.