Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Marquis Oregon City Post Acute Rehab during CMS and state inspections, most recent first.
The facility failed to complete the annual risk assessment for Legionella and other opportunistic waterborne pathogens in its main water system. The Water Management Program required the water management team to identify areas where these pathogens could grow and spread, but the last documented assessment was completed on 3/27/24. The Administrator and Maintenance Director acknowledged the annual assessment had not been completed since then.
A memory care courtyard had moss on the walkway, making it slippery, and an open box of fertilizer was left next to a table in the secured outdoor area. The Administrator acknowledged the hazards, and staff reported multiple residents were actively exit seeking. In a separate event, a CNA transferred a resident with dementia using a sit-to-stand lift without the required second staff member, despite the care plan calling for two-person assistance for all transfers.
The facility did not ensure a clean environment in the memory care unit and dining hall. Observations revealed debris and dead insects in ceiling lights and vent covers. The Maintenance Director admitted to infrequent cleaning, acknowledging the design of the fixtures contributed to the issue.
A LTC facility was found to have a medication error rate of 18%, exceeding the acceptable 5% threshold. Errors included a staff member failing to administer a probiotic to a resident with dementia, applying only one lidocaine patch instead of two for a resident with knee pain, and incorrect dosing of apripazole for a resident with depression. Additionally, residents were not instructed to rinse after using inhalers, as required by physician orders.
The facility failed to ensure proper medication storage by keeping expired biologicals in the medication room. Three open vials of Aplisol, a tuberculosis test solution, were found in the medication storage refrigerator with open dates exceeding the manufacturer's recommended discard period of 30 days. This was confirmed by the DNS, who acknowledged the need for the vials to be discarded, placing residents at risk for diminished treatment efficacy.
A resident with dementia and behavioral disturbances physically assaulted another resident in their shared room, leading to distress and a refusal to return to the room by the victim. A CNA intervened to stop the assault, and the incident was confirmed by an LPN and the DNS, highlighting a failure to protect residents from abuse.
A facility failed to accurately code the MDS regarding a resident's use of hearing devices. The resident, with Parkinson's and anxiety, was documented as not using hearing aids in the MDS, despite needing elevated tones for communication. Staff later confirmed the resident did use hearing aids, acknowledging inaccuracies in the MDS and CAA.
A resident with dementia and anxiety was not consistently assisted with wearing hearing aids, despite a care plan requiring staff to do so. Observations and interviews revealed that the resident often did not have the hearing aids in place, and staff failed to document refusals or offer assistance as needed. This deficiency in care was noted by family members and confirmed by staff.
A resident with a history of inappropriate sexual behavior was observed with their hand down another resident's pants in the dining room. The incident occurred when the supervising staff briefly left the room. Despite the resident's care plan requiring close supervision, the facility failed to implement these measures effectively, leading to the incident.
Water Management Risk Assessment Not Completed
Penalty
Summary
The facility failed to conduct an annual risk analysis assessment for potential areas of growth and spread of water-borne pathogens in its main water system. The facility’s revised Water Management Program-Legionella stated that the water management team is to complete a risk assessment annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility’s water system. A review of the facility’s Identifying Buildings at Increased Risk assessment showed it was completed on 3/27/24, and Staff 1 (Administrator) and Staff 3 (Maintenance Director) acknowledged on 2/26/26 at 11:05 AM that the annual risk analysis assessment had not been completed since that date.
Unsafe Courtyard Conditions and Improper Resident Transfer
Penalty
Summary
The facility failed to ensure the resident-accessible outdoor space in the memory care unit was free from environmental hazards. During a walkthrough of the secured fenced courtyard, the walkway was observed to have moss growth and was slippery when walked on, and a box of fertilizer was found in an open plastic box next to a table in the courtyard. The Administrator acknowledged the slippery walkway and stated the fertilizer was a hazard to the memory care residents. Staff also provided a list showing 10 residents in the memory care unit were actively exit seeking, and the Administrator later confirmed the outdoor space presented safety risks to those residents. The facility also failed to safely transfer a resident who had dementia and required a sit-to-stand mechanical lift with two staff for all transfers. The resident’s comprehensive care plan, revised in September 2024, specified the need for two staff during transfers. However, a CNA was observed transferring the resident from bed to wheelchair using a sit-to-stand lift without a second staff member present. The CNA later stated she had transferred the resident independently and that it was a lapse in judgment, and the DNS confirmed the resident required two staff for safe sit-to-stand transfers because the resident often moved during the transfer.
Facility Fails to Maintain Clean Environment in Memory Care Unit and Dining Hall
Penalty
Summary
The facility failed to maintain a clean and homelike environment in both the memory care unit and the main dining hall, as observed by surveyors. During a lunch service observation, eight ceiling lights in the main dining room were found to have accumulated debris and dead insects. Similarly, in the memory care unit, debris and dead insects were observed on two vent covers and within a ceiling light fixture. The Maintenance Director, identified as Staff 14, admitted to cleaning vents annually and addressing light fixtures only when they appeared dirty or when notified by others. He acknowledged the design of the light fixtures contributed to the accumulation of dust and insects, and confirmed that the vents and light fixtures were not clean.
High Medication Error Rate in LTC Facility
Penalty
Summary
The facility was found to have a medication error rate of 18%, which is significantly higher than the acceptable threshold of 5%. This was determined through observations, interviews, and record reviews. Several incidents contributed to this high error rate. For instance, a staff member failed to administer acidophilus pectin to a resident with dementia, despite indicating in the medication administration record (MAR) that it had been given. The staff member later admitted to not administering the medication due to its unavailability in the medication cart. Another resident with right knee pain was supposed to receive two lidocaine patches as per physician orders, but only one was applied. The staff member was unaware of the correct order, which was confirmed by the RNCM who emphasized the importance of following physician orders. Further errors involved a resident with depression who did not receive the correct dose of apripazole and was not instructed to rinse and spit after using an inhaler, as per physician orders. Similarly, another resident with chronic obstructive pulmonary disease was not instructed to rinse their mouth after using an inhaler. In both cases, the staff member acknowledged the oversight and the RNCM reiterated the expectation for staff to adhere to physician orders. These errors collectively contributed to the facility's high medication error rate, placing residents at risk for inaccurate medication dosage and potential adverse consequences.
Expired Biologicals Found in Medication Storage
Penalty
Summary
The facility failed to ensure proper medication storage by keeping expired biologicals in the medication room, specifically in the medication storage refrigerator. During an observation, three open vials of Aplisol, a tuberculosis test solution, were found with open dates exceeding the manufacturer's recommended discard period of 30 days. This oversight was confirmed by Staff 2, the Director of Nursing Services (DNS), who acknowledged that the vials had been open for more than 30 days and needed to be discarded. This failure to adhere to proper storage guidelines placed residents at risk for diminished treatment efficacy.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from physical and mental abuse by another resident. Resident 38, who was admitted with dementia and behavioral disturbances, exhibited aggressive behavior towards Resident 32, who also had dementia with behavioral disturbances. On a specific date, a CNA heard yelling from the shared room of the two residents and found Resident 38 physically assaulting Resident 32 by straddling them and placing hands around their neck. The CNA had to intervene to separate the residents and remove Resident 32 from the room. Following the incident, Resident 32 expressed distress and reluctance to return to the shared room with Resident 38. The LPN confirmed Resident 32's distress and desire not to return to the room. The DNS acknowledged the incident and deemed Resident 38's behavior unacceptable. The report indicates that the facility's failure to prevent this incident placed residents at risk for psychosocial harm.
Inaccurate MDS Coding for Hearing Device Use
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded regarding the use of hearing devices for a resident reviewed for hearing. The resident, admitted in 2019 with diagnoses including Parkinson's and anxiety, was noted in the Annual MDS dated 8/14/24 as not using hearing aids. However, the Communication Care Area Assessment (CAA) from the same date indicated the resident had difficulty hearing and required staff to speak in an elevated tone while facing them. Despite this, the CAA also noted the resident did not use hearing aids but might need them if their hearing worsened. Interviews with Staff 3, who completed the MDS and CAA, revealed that the resident did utilize hearing aids, and both documents were acknowledged as inaccurate.
Failure to Assist Resident with Hearing Aids
Penalty
Summary
The facility failed to ensure that staff assisted a resident with wearing hearing aids, which was necessary for maintaining adequate hearing. Resident 35, who was admitted with diagnoses including dementia and anxiety, had a care plan that required staff to place hearing aids in the resident's ears in the morning and remove them at night. Despite this, observations and interviews revealed that the resident often did not have the hearing aids in place, and there was no documentation indicating that the resident refused to wear them. A family member reported that the resident never had the hearing aids in during visits, and the resident confirmed needing assistance with them. Staff interviews indicated that while some staff acknowledged the resident's need for hearing aids, they did not consistently offer assistance or document refusals as required. Multiple staff members, including CNAs and an RNCM, confirmed that the resident was hard of hearing and required help with the hearing aids. Despite the care plan instructions and family concerns, the hearing aids were often left on the nightstand, and staff did not always respond to the resident's requests for assistance, leading to a deficiency in care.
Failure to Protect Residents from Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect residents from abuse, specifically involving Resident 7 and Resident 8. Resident 7, who was admitted in March 2020 with severe cognitive impairment, was involved in an incident where Resident 8, who had a history of inappropriate sexual behavior, was observed with their hand down the front of Resident 7's pants. This incident occurred in the dining room while the residents were watching a movie, and the staff member responsible for supervision had briefly left the room. Upon returning, the staff member separated the residents and assessed Resident 7, who did not show signs of psychosocial distress. Resident 8, admitted in August 2022 with moderate cognitive impairment, had a documented history of inappropriate sexual behavior, including touching other residents without consent. Despite this, the care plan interventions, such as one-to-one supervision and seating arrangements, were not effectively implemented, leading to the incident with Resident 7. The facility's failure to ensure adequate supervision and adherence to the care plan interventions placed residents at risk for abuse.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Oregon City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rivercrest Post Acute | 0.6 mi | ★★★★★ | 20 | 0 |
| Avamere Rehabilitation Of Oregon City | 1.5 mi | ★★★★★ | 1 | 0 |
| Avamere Rehabilitation Of Clackamas | 3.5 mi | ★★★★★ | 6 | 0 |
| Rose Linn Care Center | 3.7 mi | ★★★★★ | 12 | 0 |
| Fernwood Supportive Living At Madrona Grove | 7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.