Marquis Forest Grove Post Acute Rehab

In the surveyor’s words

From the most serious findings on record at Marquis Forest Grove Post Acute Rehab, in the surveyor’s own words.

• Actual harm, isolatedF658Apr 10, 2026

  Based on interview and record review it was determined the facility failed to ensure staff adhered to professional standards during medication administration for 1 of 1 licensed nurse (#3) reviewed for significant medication error. Resident 49 required emergency treatment and was hospitalized for monitoring due to a methadone overdose. Findings include:Resident 49 admitted to the facility in 2021 with diagnoses including COPD and diabetes. Staff 3's employee file indicated on 10/13/25 education was provided regarding where to find crushed medication orders for Resident 49. The education was provided because Staff 3 gave whole medications to the resident and she/he choked on the whole medications. Resident 49's orders were reviewed with Staff 3. […]

• Actual harm, isolatedF760Apr 10, 2026

  Based on interview and record review it was determined the facility failed to ensure a resident was free from a significant medication error for 1 of 1 sampled resident (#49) reviewed for significant medication error. Resident 49 required emergency treatment and was hospitalized for monitoring due to a methadone (narcotic pain medication) overdose. Findings include:Resident 49 admitted to the facility in 2021 with diagnoses including COPD and diabetes. The 11/3/25 8:37 AM signed medication error report written by Staff 3 (LPN) indicated the following: This LN [licensed nurse] asked CNA in dining room who room [Resident 41] was and when she pointed with her head it was towards [Resident 49], so this LN gave methadone to [Resident 49] instead of [Resident 41], no side effects noted at this… […]

• No harm, potential for more than minimal, patternF761Nov 22, 2024

  Based on observation, interview, and record review it was determined the facility failed to ensure appropriate medication storage temperatures were logged and maintained and failed to ensure proper labeling of biologicals for 1 of 1 medication storage refrigerator and 1 of 3 treatment carts reviewed for safe medication storage. This placed residents at risk for receiving medications with reduced efficacy. Findings include: 1. On 11/21/24 at 11:18 AM one open, undated vial of tuberculin (used for the testing in the diagnosis of Tuberculosis) was observed in the medication room refrigerator. The manufacturer's instructions indicated to discard the medication 30 days after opening. […]

• No harm, potential for more than minimal, patternF880Nov 22, 2024

  Based on observation, interview, and record review it was determined the facility failed to process laundry to produce hygienically clean laundry and prevent the spread of infection for 1 of 1 laundry room reviewed for infection control. This placed residents at risk for contaminated laundry. Findings include: According to the Center for Disease Control and Prevention: Guidelines for Environmental Control in Healthcare Facilities (2003); Laundry and Bedding Section G.II.D, damp laundry was not to be left in machines overnight. On 11/21/24 at 1:48 PM Staff 11 (Housekeeping) stated her shift ended at 2:30 PM and she had the last shift of the day. […]

• No harm, potential for more than minimal, isolatedF695Nov 22, 2024

  Based on observation, interview, and record review it was determined the facility failed to ensure resident respiratory equipment was maintained for 1 of 1 sampled resident (#12) 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 12 was admitted to the facility in 10/2023 with diagnoses including Chronic Obstructive Pulmonary Disorder (a lung disease causing restricted airflow and breathing problems) and depression. The 10/19/24 Annual MDS indicated Resident 12 was cognitively intact. Resident 12's physician order dated 11/1/24 revealed she/he required oxygen nightly and as needed. […]