Marquis Wilsonville Post Acute Rehab

Based on observation, interview and record review it was determined the facility failed to provide adequate nail care for 1 of 1 sampled resident (#32) reviewed for ADLs. This placed residents at risk for poor hygiene. Findings include: Resident 32 was admitted to the facility in 3/2026 with diagnoses including fracture of the left leg.Resident 32's 3/25/26 Personal Hygiene Care Plan directed the resident's hygiene needs would be met and the resident required constant supervision and physical assistance from staff with hand washing. Resident 32's 3/31/26 admission MDS indicated the resident was cognitively impaired and required substantial to maximum staff assistance for personal hygiene. Observations from 4/6/26 through 4/7/26 between the hours of 8:37 AM and 12:44 PM revealed Resident 32's fingernails and cuticles on both hands were coated in dark, black thick debris collected underneath the nails and built up around the cuticles.Resident 32's health record did not include documented evidence specific to the provision of nail care. On 4/6/26 at 10:14 AM Resident 32 was unable to…

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 observation, interview, and record review it was determined the facility failed to ensure resident respiratory equipment was maintained for 1 of 2 sampled residents (#44) reviewed for respiratory care. This placed residents at risk for increased respiratory concerns. Findings include:A 3/2015 Oxygen Administration facility policy indicated oxygen concentrator filters were to be cleaned weekly. Resident 44 admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia. Resident 44's physician order dated 3/30/26 revealed she/he required supplemental oxygen use to maintain oxygen saturation. On 4/6/26 at 1:49 PM and on 4/7/26 at 11:30 AM the oxygen concentrator was observed to have an external foam filter with a thick layer of dust. On 4/7/26 at 3:30 PM Staff 3 (Interim DNS/Corporate RN) acknowledged Resident 44's concentrator foam filter was covered in a thick layer of dust. Staff 3 stated she expected the filters to 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.

Based on interview and record review it was determined the facility failed to develop a comprehensive, person-centered care plan for 1 of 1 sampled resident (#27) reviewed for ADLs. This placed residents at risk for unmet bathing, grooming and vision needs. Findings include: Resident 27 was admitted to the facility in 9/2024 with diagnoses including Alzheimer's disease and macular degeneration (vision impairment). a. Resident 27's 9/15/24 admission MDS indicated the resident wore glasses and it was very important to read. The vision CAA, completed by Staff 5 (Social Services) indicated the following: - ensure glasses were clean and appropriately worn. Resident 27's 9/2024 Care Plan did not include a focus, goals or interventions related to her/his vision and the use of glasses. On 12/17/24 at 1:27 PM, 1:47 PM and 2:01 PM Staff 10 (CNA), Staff 11 (CNA) and Staff 12 (RN) stated they referred to the Care Plan to determine Resident 27's care needs. Staff 10, Staff 11 and Staff 12 stated they were not sure if Resident 27 wore glasses. On 12/18/24 at 11:22 AM Staff 5 stated her role…

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 the resident was involved and informed of the discharge plan for 1 of 2 sampled residents (#30) reviewed for care planning. This placed residents at risk for being uninformed about their discharge plan. Findings include: Resident 30 was admitted to the facility in 11/2024 with diagnoses including Raynaud's syndrome (disorder of the blood vessels). Resident 30's 9/15/24 admission MDS indicated the resident was cognitively intact. Resident 30's 11/8/24 Discharge Care Plan, created by Staff 5 (Social Services) indicated the following: - Anticipated discharge plan is to: HLOC, prefers AFH No other information was found on the Care Plan related to Resident 30's discharge plan. Resident 30's 11/14/24 Care Conference indicated the discharge plan was reviewed with the resident and the projected discharge date was 12/11/24. On 12/16/24 at 11:44 AM Resident 30 stated she/he did not feel included in the discharge plan. The resident stated nobody ever talked to me or kept her/him informed about where or 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.

Based on observation, interview and record review it was determined the facility failed to provide adequate bathing and grooming for 1 of 1 sampled resident (#27) reviewed for ADLs. This placed residents at risk for poor hygiene and grooming. Findings include: Resident 27 was admitted to the facility in 9/2024 with diagnoses including Alzheimer's disease, restlessness and agitation. Resident 27's 9/15/24 admission MDS indicated the resident had severe cognitive impairment and required moderate staff assistance for personal hygiene and grooming. Resident 27's 9/2024 Bathing and Personal Hygiene Care Plan indicated the resident required staff assistance and constant supervision for bathing and personal hygiene and the resident's hygiene needs will be met. Resident 27's Bath/Shower Task Flowsheet revealed the resident did not receive a bath/shower for 27 days between 11/19/24 through 12/15/24. On 12/16/24 at 4:11 PM Witness 2 (Family) stated the resident used to be clean shaven all the time. On 12/16/24 at 10:33 AM and 12/17/24 at 1:15 PM Resident 27 had long, unkempt facial hair.…

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 residents received vision services for 1 of 1 sampled resident (#27) reviewed for vision. This placed residents at risk for unmet vision needs. Findings include: Resident 27 was admitted to the facility in 9/2024 with diagnoses including macular degeneration (vision impairment). Resident 27's 9/15/24 admission MDS indicated the resident wore glasses and it was very important to read. The vision CAA, completed by Staff 5 (Social Services) indicated the following: - Ensure glasses were clean and appropriately worn; - Resident has macular degeneration that impairs vision. [Resident] has a visual deficit and has glasses [she/he] does not use because [she/he] needs a new glasses prescription. [Resident stated] They aren't the correct prescription any way. Resident 27's health record revealed no evidence the facility facilitated vision services to ensure the resident was assessed for glasses and had the appropriate prescription. 12/16/24 at 4:14 PM Witness 2 (Family) stated Resident 27…

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 pharmacy recommendations were followed up on for 1 of 5 sampled residents (#10) reviewed for medications. This placed residents at risk for adverse medication reactions. Findings include: Resident 10 was admitted to the facility in 2/2024 with diagnoses including depression and hypotension. Monthly pharmacist reviews of Resident 10's medication regimen revealed the following: -On 11/4/24 the pharmacist recommendation advised the prescriber to discontinue PRN haloperidol after 14 days (11/15/24). If necessary, write a new order x 14 days only after direct examination and documentation is completed. No response from the provider was found in Resident 10's health care record or provided by the facility. -On 11/4/24 the pharmacist recommendation advised the prescriber to provide the following rationale and duration: It is appropriate for PRN lorazepam to be extended beyond 14 days. Medication necessary to help with comfort as resident transitions towards end-of-life. Continue order for 6 months at which…

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 ensure residents were free from unnecessary bowel medication for 1 of 3 sampled residents (#3) reviewed for medication. This placed residents at risk for adverse medication side effects. Findings include: Resident 3 admitted to the facility on [DATE] with diagnoses including stroke and post hospital procedure for intestinal obstruction. The 4/16/24 hospital orders indicated Resident 3 was to receive loperamide 2 mg (antidiarrheal medication) two capsules twice daily and one capsule every six hours as needed for diarrhea. The 4/17/24 order indicated Resident 3 was to receive Miralax powder (laxative medication) once daily for bowel care. Hold for loose stools. The 4/2024 MARs indicated Resident 3 received Miralax once daily from 4/17/24 through 4/29/24. Resident 3's bowel records indicated the following dates when she/he had loose or watery stools on one or more occasions: -4/17/24 -4/18/24 -4/19/24 -4/21/24 -4/23/24 -4/24/24 -4/27/24…

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.

1. Based on interview and record review it was determined the facility failed to ensure the care plan reflected management of potential complications associated with a tracheostomy tube for 1 of 1 sampled resident (#17) reviewed for respiratory care. This placed the resident at risk for delayed care. Findings include: Resident 17 was admitted to the facility on 9/2022 with diagnoses including acute and chronic respiratory failure and history of stroke. The resident had a permanent tracheostomy (an opening in the front of the neck into the windpipe [trachea] with a tube in the opening to keep it open for breathing.) Resident 17's comprehensive Care Plan dated 12/12/22 (last reviewed 7/10/23) included a focus area related to impaired/compromised respiratory function and ability to communicate related to the tracheostomy. The care plan did not include information related to the availability of spare inner or outer tracheostomy tubes at the resident's bedside or emergency management of complications associated with the tracheostomy tube. On 8/23/23 at 11:34 AM Staff 4 (LPN) confirmed…

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.