Cycle 1
Health 2024-10-24 · Fire 2024-10-24
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Oregon City, OR
Marquis Oregon City Post Acute Rehab
4-star overall rating with 2-star inspections with abuse icon flag with 6 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
1680 Molalla Avenue, Oregon City, OR
(503) 655-2588
Overall
4 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
102
Certified beds
Average residents
52
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Marquis Companies
Operator or chain grouping
Approved since
1990-10-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 facilities
Chain averages 4 overall / 4 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.52
Registered nurse staffing · state 0.68 · national 0.68
LPN hours / resident day
1.03
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
3.64
Nurse aide staffing · state 3.37 · national 2.35
Total nurse hours
5.18
All reported nurse hours · state 4.95 · national 3.89
Licensed hours
1.55
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
4.70
Weekend nurse staffing · state 4.39 · national 3.43
Weekend RN hours
0.28
Weekend registered nurse coverage · state 0.44 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.55
CMS adjusted RN staffing hours
Adjusted total hours
5.54
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 53% · national 45%
Total nurse turnover
19%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,291
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.44
Composite VBP score used to determine payment impact.
Payment multiplier
1.0046
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.27% · Performance 22.58% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.87
Baseline 6.69% · Performance 6.98% · Measure score 2.87 · Achievement 2.87 · Improvement 0
Total nurse turnover
8.88
Baseline 41.89% · Performance 27.40% · Measure score 8.88 · Achievement 8.88 · Improvement 8.01
Adjusted total nurse staffing
8.43
Baseline 5.25 hours · Performance 5.48 hours · Measure score 8.43 · Achievement 8.43 · Improvement 3.71
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.66% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 151 · Observed rate 11.26% · Lower 95% interval 8.7% |
| Discharge to community | 69.95% |
50.57%
19.4 pts better
|
Better than the National Rate · Eligible stays 166 · Observed rate 70.48% · Lower 95% interval 62.98% |
| Medicare spending per beneficiary | 0.76 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 99.04% |
95.27%
3.8 pts better
|
Numerator 103 · Denominator 104 |
| Falls with major injury | 0.96% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 104 |
| Discharge self-care score | 77.38% |
53.69%
23.7 pts better
|
Numerator 65 · Denominator 84 |
| Discharge mobility score | 59.52% |
50.94%
8.6 pts better
|
Numerator 50 · Denominator 84 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 104 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.98% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 101 · Observed rate 4.95% · Lower 95% interval 4.13% |
| Staff COVID-19 vaccination coverage | 12.87% |
8.2%
4.7 pts better
|
Numerator 13 · Denominator 101 |
| Staff flu vaccination coverage | 23.53% |
42%
18.5 pts worse
|
Numerator 24 · Denominator 102 |
| Discharge function score | 66.67% |
56.45%
10.2 pts better
|
Numerator 56 · Denominator 84 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 85 · Denominator 85 |
| Resident COVID-19 vaccinations up to date | 38.46% |
25.2%
13.3 pts better
|
Numerator 20 · Denominator 52 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 83.9% |
95.5%
11.6 pts worse
|
93.4%
9.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 86.5% · Q2 79.5% · Q3 86.5% · Q4 83.3% · 4Q avg 83.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 81.0% |
95.2%
14.2 pts worse
|
95.5%
14.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 81.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
2.4%
0.3 pts worse
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 2.7% · Q4 5.6% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.7%
4.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 10.2% |
5.0%
5.2 pts worse
|
5.4%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 8.3% · Q3 9.1% · Q4 9.4% · 4Q avg 10.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.8% |
12.5%
6.7 pts better
|
19.6%
13.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 5.4% · Q3 3.0% · Q4 3.0% · 4Q avg 5.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 26.4% |
14.7%
11.7 pts worse
|
16.7%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 31.2% · Q3 24.0% · Q4 32.0% · 4Q avg 26.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 25.6% |
24.1%
1.5 pts worse
|
16.3%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.1% |
15.8%
0.3 pts worse
|
14.9%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 5.9% · Q3 16.7% · Q4 17.2% · 4Q avg 16.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.7%
1.7 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
2.0%
0.7 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 0.0% · Q3 2.7% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.3% |
22.2%
2.9 pts better
|
19.8%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 11.4% · Q3 16.7% · Q4 29.8% · 4Q avg 19.3% |
| Percentage of long-stay residents with pressure ulcers | 11.3% |
6.5%
4.8 pts worse
|
5.1%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 14.2% · Q3 13.9% · Q4 8.0% · 4Q avg 11.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.4% |
85.4%
2 pts better
|
81.7%
5.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 81.1% · Q2 89.9% · Q3 90.3% · Q4 87.7% · 4Q avg 87.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.0% |
15.1%
12.1 pts better
|
12.0%
9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.0% · Observed 2.9% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.7%
0.8 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 1.2% · Q4 1.4% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.4% |
81.2%
4.8 pts worse
|
79.7%
3.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.7% |
21.6%
3.1 pts worse
|
23.9%
0.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.7% · Observed 21.4% · Expected 20.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-08-30 · Fire 2019-08-30
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2018-02-16 · Fire 2018-02-16
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-24
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-12-13
F · Potential for more than minimal harm
2024-10-24
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-12-13
F · Potential for more than minimal harm
2024-10-24
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-12-13
F · Potential for more than minimal harm
2024-10-24
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2024-12-13
F · Potential for more than minimal harm
2024-10-24
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2024-12-13
F · Potential for more than minimal harm
2024-10-24
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2024-12-13
F · Potential for more than minimal harm
2024-10-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-13
F · Potential for more than minimal harm
2024-10-24
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-12-13
F · Potential for more than minimal harm
2024-10-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-10-24
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-10-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-10-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-13
E · Potential for more than minimal harm
2019-08-30
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2019-10-19
E · Potential for more than minimal harm
2019-08-30
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-10-19
D · Potential for more than minimal harm
2019-08-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-10-19
F · Potential for more than minimal harm
2018-02-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2018-04-19
F · Potential for more than minimal harm
2018-02-16
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2018-04-19
D · Potential for more than minimal harm
2018-02-16
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2018-04-19
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-10-24
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-10-24
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-10-24
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-10-24
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-10-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-10-24
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-07-29
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-08-10
D · Potential for more than minimal harm
2019-08-30
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2019-10-19
D · Potential for more than minimal harm
2019-08-30
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2019-10-19
D · Potential for more than minimal harm
2019-08-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-10-19
D · Potential for more than minimal harm
2019-08-30
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2019-10-19
E · Potential for more than minimal harm
2018-02-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2018-04-07
D · Potential for more than minimal harm
2018-02-16
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2018-04-07
D · Potential for more than minimal harm
2018-02-16
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2018-04-07
Penalties and ownership
What sits behind the stars
Ownership
Fogg, Phillip
5% Or Greater Indirect Ownership Interest · Individual
Marquis Companies I, Inc
5% Or Greater Direct Ownership Interest · Organization
Bucher, Amy
Operational/Managerial Control · Individual
Bucher, Amy
Contracted Managing Employee · Individual
Fogg, Phillip
Corporate Officer · Individual
Fogg, Steven
Operational/Managerial Control · Individual
Fogg, Steven
Corporate Officer · Individual
Fogg, Steven
Contracted Managing Employee · Individual
Levee, Kathleen
Operational/Managerial Control · Individual
Levee, Kathleen
Contracted Managing Employee · Individual
Marquis Companies I, Inc
Operational/Managerial Control · Organization
Olum, April
Operational/Managerial Control · Individual
Tone, Staci
Operational/Managerial Control · Individual
Tone, Staci
Contracted Managing Employee · Individual
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#2
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3-star overall rating with 2-star inspections with $85,768 in total fines with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Avamere Rehabilitation Of Clackamas
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3-star overall rating with 3-star inspections with $175,773 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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