Marquis Tualatin Post Acute Rehab

Based on observation and interview it was determined the facility failed to store food in a sanitary manner for 1 of 1 resident refrigerator reviewed for sanitary food storage and handling. This placed residents at risk for food-borne illness and contamination. Findings include:On 5/18/26 at 10:46 AM during the initial tour of the facility's dining room and kitchenette the following was observed in the communal freezer:-An opened ice cream bar, uncovered, not labeled or dated.-A small ice cream container covered with a plastic lid, not labeled or dated.-Dried brown substance smudged on the sides of the freezer wall.-Spilled substance stuck on the bottom of the freezer shelf.On 5/18/26 Staff 1 (Administrator) and Staff 17 (Dietary Manager) observed the items with the surveyor and indicated the items in the freezer needed to be thrown away and the spilled substances needed to be cleaned.

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 personal hygiene for 1 of 2 sampled residents (#26) reviewed for ADLs. This placed residents at risk for poor hygiene. Findings include: Resident 26 was admitted to the facility in 10/2022 with diagnoses including Parkinson's.The 2022 [NAME] Standards of Care indicated the following: -Staff were required to shave residents as needed. A 10/2022 Care Plan indicated Resident 26 required supervision with cueing and assistance during shaving. A 4/27/26 Quarterly MDS indicated Resident 26 had a BIMS score of 15 indicating she/he was cognitively intact. The 5/18/26 and 5/21/26 Medical Record indicated Staff 8 (CNA) and Staff 9 (CNA) provided assistance to complete personal hygiene.During random observations from 5/18/26 through 5/21/26 from 8:00 AM to 4:00 PM, Resident 9's beard was unkempt. Resident 9's beard was overgrown with gray and brown hairs. On 5/20/26 at 9:18 AM, Resident 26 stated staff did not offer to assist…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to follow physician orders for 2 of 6 sampled residents (#s 18 and 31) reviewed for dialysis and medications. This placed residents at risk for worsening medical conditions. Findings include:1. Resident 18 was admitted to the facility in 5/2026 with diagnoses including kidney failure and diabetes. A review of Resident 18's current physician orders indicated the following medication and treatment: -Aspirin daily for heart health. -Vitamin B12 for a daily supplement. -CBGs were to be taken in the morning and at bedtime. Resident 18's 5/2026 MAR revealed the resident did not receive Aspirin, Vitamin B12 or have her/his CBGs checked on the mornings of 5/9, 5/12, 5/14, 5/16, 5/19 and 5/20. On 5/21/26 at 10:23 AM Staff 6 (RN) stated Resident 18 had dialysis early in the morning on Tuesday, Thursday and Saturday. Staff 6 stated on the days the resident had dialysis she/he did not receive her/his morning medications and CBG checks due to being…

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.

Based on observation, interview and record review it was determined the facility failed to ensure staff assisted residents with use of a prescribed boot to prevent a potential decrease in ROM or mobility for 1 of 1 sampled resident (#5) reviewed for ADLs. This placed residents at risk for loss of ROM and mobility. Findings include:Resident 5 was admitted to the facility in 2/2026 with diagnoses including a stroke.Resident 5's 2/15/26 admission MDS indicated the resident had severe cognitive impairment and a range of motion impairment on her/his lower extremity.Resident 5's revised 4/27/26 Care Plan revealed the resident required a contracture boot to be placed on her/his right foot for two hours on and two hours off.Random observations between 5/18/26 from 10:00 AM and 5/21/26 at 9:05 AM revealed Resident 5's contracture boot sat on the chair next to the resident's bed and revealed no instances of Resident 5 with the contracture boot on her/his foot.On 5/19/26 at 12:28 AM Witness 3 (Family Member) stated Resident 5 was supposed to have a support boot placed onto her/his right foot.…

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.

Based on observation, interview and record review it was determined the facility failed to properly disinfect a shared glucometer between resident uses for 1 of 5 sampled residents (#1) reviewed for infection control during CBG checks. This placed residents at risk for exposure to infection. Findings include: The undated facility Glucometer Disinfection Policy indicated to disinfect after each individual patient use with EPA disinfectant wipes.A 2017 Evencare G2 Glucometer Manufacturer Manual indicated, Disinfect common use glucometers with the use of approved disinfectant wipes. The glucometer was to be wiped with the disinfecting wipe and left wet for two minutes to ensure disinfection. On 5/19/26 at 12:12 PM, Staff 6 was observed to obtain a CBG for Resident 31. Staff 6 returned to the medication cart, wiped the glucometer with an alcohol pad wipe, which was not an EPA-approved disinfecting wipe, and placed the glucometer back inside the cart. Staff 6 stated she always cleaned the glucometers with an alcohol pad wipe after use, and she believed other staff cleaned it the same…

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.

Based on observation, interview and record review it was determined the facility failed to ensure medications and biologicals were secured for 1 of 4 medication and 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 pass to prevent unauthorized entry. -The medication cart must be securely locked at all times when out of the nurse's view. a. On 2/26/25 at 11:38 AM, the medication cart adjacent to the nursing station entered A-hall was unlocked and unattended. At 11:40 AM Staff 6 (RN) entered the A-hallway with a different medication and treatment cart. As Staff 6 passed by the unlocked and unattended cart she was observed to push in the lock on the cart to secure it and kept walking. Staff 6 went to a resident's room nearby and Staff 5 (RN) was observed to exit that same resident's room. During an interview with Staff 5 and Staff 6 on 2/26/25 at…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to prevent misappropriation of financial resources by Staff 7 (Former Agency CNA) for 1 of 1 sampled resident (#145) reviewed for misappropriation of property. This placed residents at risk for misuse of personal funds. Findings include: The facility's 5/2010 Misappropriation of Property- Lost Items policy specified misappropriation of resident property as the patterned or deliberate exploitation of a resident's belongings or money without the resident's consent. Resident 145 was admitted to the facility in 10/2024 with diagnoses including right femur fracture (a break in the thigh bone). The 10/16/24 admission MDS indicated Resident 145 was cognitively intact. Resident 145 discharged from the facility on 11/2/24. A 12/4/24 FRI indicated on 12/4/24 Witness 1 (Family) reported to Staff 1 (Administrator) a fraudulent check was written from Resident 145's check book while a resident at the facility. The check was made out to Staff 7 while…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to thoroughly investigate alleged misappropriation of property for 1 of 1 sampled resident (#145) reviewed for abuse. This placed residents at risk for misuse of personal funds. Findings include: The facility's 5/2010 Misappropriation of Property- Lost Items policy specified when an incident of misappropriation of resident property was reported, the administrator would appoint a staff member to investigate the incident. The investigation would consist of the following: -An interview with the resident. -An interview with the employee(s) accused of taking the resident's property. -A review of the resident's personal inventory record to determine if missing items were recorded on the report. -Interviews with staff members (on all shifts as applicable) having contact with the resident. Resident 145 was admitted to the facility in 10/2024 with diagnoses including right femur fracture (a break in the thigh bone). The 10/16/24 admission MDS…

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.

Based on interview and record review the facility failed to notify a resident's representative of a fall for 1 of 3 sampled residents (#1) reviewed for falls. This placed resident representatives at risk for being uninformed of resident accidents. Findings include: Resident 1 was admitted to the facility in 11/2023 with diagnoses including BPH (benign prostatic hyperplasia) and depression. Resident 1's admission Record revealed Witness 15 (Family Member) was Resident 1's resident representative and emergency contact. No information was found in the clinical record to indicate Witness 15 signed paperwork as Resident 1's resident representative. On 6/5/24 at 12:48 PM Witness 15 stated Resident 1 fell at the facility on the morning of 12/3/23, and no one from the facility contacted Witness 15 regarding the incident. On 6/6/24 at 11:22 AM Staff 12 (LPN) stated she did not contact the family after Resident 1's fall because the resident was her/his own representative. On 6/6/24 at 12:47 PM Staff 4 (RNCM) stated Witness 15 should have been notified of the fall if Witness 15 was Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to ensure residents received care plan interventions for safe transfer and failed to ensure residents were monitored after a fall for 1 of 3 sampled residents (#1) reviewed for accidents. This placed residents at risk for latent injury. Findings include: Resident 1 was admitted to the facility in 11/2023 with diagnoses including BPH (benign prostatic hyperplasia) and depression. A review of the resident's care plan, dated 11/28/23, indicated Resident 1 required a two-person mechanical lift with transfers, wore non skid socks when out of bed, and the call light was to be within reach. a. A Fall/Post Fall Assessment and Investigation dated 12/3/24 revealed the following: -At 9:45 AM, Resident 1 was found on the floor next to the left side of her/his bed by Staff 12 (LPN). -The resident was previously sitting in her/his wheelchair and Staff 12 heard Resident 1 calling for help. -Resident 1 stated she/he became dizzy and fell forward out of the wheelchair. -The resident was toileted at 7:00 AM and was last…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to provide appropriate catheter care for a resident's urinary catheter for 1 of 3 sampled residents (#1) reviewed for catheter care. This placed residents at increased risk for infection. Findings include: Resident 1 was admitted to the facility in 11/2023 with diagnoses including BPH (benign prostatic hyperplasia) and hematuria (blood in the urine). A Nursing admission Assessment, dated 11/28/23 at 9:19 AM, revealed Resident 1 admitted due to urosepsis (a urinary tract infection which spreads to the kidneys) with hematuria. The resident had a urinary catheter with a large amount of hematuria present. The resident was at risk for functional incontinence related to weakness, impaired mobility, and dependence on staff to meet mobility and toileting needs. Resident 1 was care planned for staff assistance with toileting, used a large brief, received daily urinary catheter care, and skilled therapy services to promote toileting safety 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.