Cycle 1
Health 2024-12-06 · Fire 2024-12-06
2 health deficiencies
Top issue: Infection Control (1 deficiency)
10 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Portland, OR
Marquis Piedmont Post Acute Rehab
4-star overall rating with 5-star inspections with 2 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
319 Ne Russet, Portland, OR
(503) 289-5571
Overall
4 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
70
Certified beds
Average residents
47
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Marquis Companies
Operator or chain grouping
Approved since
1989-09-14
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
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.71
Registered nurse staffing · state 0.68 · national 0.68
LPN hours / resident day
0.72
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.14
Nurse aide staffing · state 3.37 · national 2.35
Total nurse hours
3.57
All reported nurse hours · state 4.95 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.31
Weekend nurse staffing · state 4.39 · national 3.43
Weekend RN hours
0.54
Weekend registered nurse coverage · state 0.44 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.68
CMS adjusted RN staffing hours
Adjusted total hours
3.44
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
75%
Annual RN turnover · state 53% · national 45%
Total nurse turnover
68%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,714
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.23
Composite VBP score used to determine payment impact.
Payment multiplier
0.9889
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.68
Baseline 18.46% · Performance 20.65% · Measure score 1.68 · Achievement 1.68 · Improvement 0
Healthcare-associated infections
4.16
Baseline 5.90% · Performance 6.59% · Measure score 4.16 · Achievement 4.16 · Improvement 0
Total nurse turnover
0
Baseline 58.33% · Performance 67.07% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
8.25
Baseline 4.71 hours · Performance 5.42 hours · Measure score 8.25 · Achievement 8.25 · Improvement 6.17
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.04% |
10.72%
1.7 pts better
|
No Different than the National Rate · Eligible stays 128 · Observed rate 5.47% · Lower 95% interval 6.32% |
| Discharge to community | 57.63% |
50.57%
7.1 pts better
|
No Different than the National Rate · Eligible stays 138 · Observed rate 54.35% · Lower 95% interval 50.04% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.67% |
95.27%
3.4 pts better
|
Numerator 74 · Denominator 75 |
| Falls with major injury | 1.33% |
0.77%
0.6 pts worse
|
Numerator 1 · Denominator 75 |
| Discharge self-care score | 54.72% |
53.69%
1 pts better
|
Numerator 29 · Denominator 53 |
| Discharge mobility score | 43.4% |
50.94%
7.5 pts worse
|
Numerator 23 · Denominator 53 |
| Pressure ulcers or injuries, new or worsened | 2.67% |
2.29%
0.4 pts worse
|
Numerator 2 · Denominator 75 · Adjusted rate 3.59% |
| Healthcare-associated infections requiring hospitalization | 6.59% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 83 · Observed rate 4.82% · Lower 95% interval 3.89% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 86 |
| Staff flu vaccination coverage | 37.38% |
42%
4.6 pts worse
|
Numerator 40 · Denominator 107 |
| Discharge function score | 47.17% |
56.45%
9.3 pts worse
|
Numerator 25 · Denominator 53 |
| Transfer of health information to provider | 96.15% |
95.95%
0.2 pts better
|
Numerator 25 · Denominator 26 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 45 · Denominator 45 |
| Resident COVID-19 vaccinations up to date | 37.78% |
25.2%
12.6 pts better
|
Numerator 17 · Denominator 45 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
95.5%
2.8 pts better
|
93.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.8% · Q2 100.0% · Q3 100.0% · Q4 96.8% · 4Q avg 98.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.2%
4.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
2.4%
0.1 pts worse
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.4% · Q3 3.4% · Q4 0.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.4% |
4.7%
2.7 pts worse
|
11.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 11.5% · Q3 3.7% · Q4 6.9% · 4Q avg 7.4% |
| Percentage of long-stay residents who lose too much weight | 13.4% |
5.0%
8.4 pts worse
|
5.4%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 22.2% · Q3 11.1% · Q4 3.3% · 4Q avg 13.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.7% |
12.5%
5.2 pts worse
|
19.6%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 14.8% · Q3 14.8% · Q4 26.7% · 4Q avg 17.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.8% |
14.7%
9.1 pts worse
|
16.7%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 25.0% · Q3 20.0% · Q4 23.1% · 4Q avg 23.8% · 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 need for help with daily activities has increased | 21.5% |
15.8%
5.7 pts worse
|
14.9%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.0% · Q2 22.7% · Q3 10.0% · Q4 15.4% · 4Q avg 21.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.4% |
1.7%
1.7 pts worse
|
1.0%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 4.1% · Q3 2.2% · Q4 2.1% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.4% |
2.0%
1.4 pts worse
|
1.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.4% · Q3 0.0% · Q4 6.5% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.4% |
22.2%
5.2 pts worse
|
19.8%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 23.8% · Q3 36.3% · Q4 23.0% · 4Q avg 27.4% |
| Percentage of long-stay residents with pressure ulcers | 12.7% |
6.5%
6.2 pts worse
|
5.1%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 18.1% · Q3 11.7% · Q4 13.3% · 4Q avg 12.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.0% |
85.4%
2.6 pts better
|
81.7%
6.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.3% · Q2 92.2% · Q3 88.1% · Q4 80.8% · 4Q avg 88.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.8% |
15.1%
1.7 pts worse
|
12.0%
4.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.8% · Observed 15.9% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.7%
1.4 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.7% |
81.2%
7.5 pts better
|
79.7%
9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.7% |
21.6%
1.1 pts worse
|
23.9%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.7% · Observed 19.0% · Expected 20.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-03-02 · Fire 2020-03-02
8 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2018-07-11 · Fire 2018-07-11
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-06
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-01-24
F · Potential for more than minimal harm
2024-12-06
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2025-01-24
F · Potential for more than minimal harm
2024-12-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-01-24
F · Potential for more than minimal harm
2024-12-06
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-01-24
F · Potential for more than minimal harm
2024-12-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-24
D · Potential for more than minimal harm
2024-12-06
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 2025-01-24
D · Potential for more than minimal harm
2024-12-06
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-01-24
D · Potential for more than minimal harm
2024-12-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-24
D · Potential for more than minimal harm
2024-12-06
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-01-24
D · Potential for more than minimal harm
2024-12-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-01-24
F · Potential for more than minimal harm
2020-03-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-04-06
D · Potential for more than minimal harm
2020-03-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2020-04-06
F · Potential for more than minimal harm
2018-07-11
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2018-07-31
F · Potential for more than minimal harm
2018-07-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2018-07-31
D · Potential for more than minimal harm
2018-07-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-07-31
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-12-06
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 2025-01-24
D · Potential for more than minimal harm
2024-12-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-24
F · Potential for more than minimal harm
2024-09-30
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-11-19
E · Potential for more than minimal harm
2024-09-30
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-11-19
D · Potential for more than minimal harm
2024-09-30
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-02-20
D · Potential for more than minimal harm
2024-09-30
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-11-19
F · Potential for more than minimal harm
2020-03-02
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 2020-04-17
D · Potential for more than minimal harm
2020-03-02
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 2020-04-17
D · Potential for more than minimal harm
2020-03-02
F758 · Pharmacy Service Deficiencies
Health
Implement 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.
Corrected 2020-04-17
D · Potential for more than minimal harm
2020-03-02
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2020-04-17
G · Actual harm
2018-07-11
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2018-08-21
D · Potential for more than minimal harm
2018-07-11
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2018-08-21
D · Potential for more than minimal harm
2018-07-11
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2018-08-21
D · Potential for more than minimal harm
2018-07-11
F758 · Pharmacy Service Deficiencies
Health
Implement 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.
Corrected 2018-10-04
D · Potential for more than minimal harm
2018-07-11
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2018-08-21
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
English, Meagan
Operational/Managerial Control · Individual
English, Meagan
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
Ohmart, Teresa
Operational/Managerial Control · Individual
Tone, Staci
Operational/Managerial Control · Individual
Tone, Staci
Contracted Managing Employee · Individual
Nearby options
Other facilities in reach
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Fernhill Rehabilitation And Care
Portland, OR
2-star overall rating with 2-star inspections with abuse icon flag with $8,278 in total fines with 17 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Porthaven Post Acute
Portland, OR
2-star overall rating with 2-star inspections with abuse icon flag with $43,788 in total fines with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Holladay Park Plaza
Portland, OR
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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