Marquis Newberg

In the surveyor’s words

From the most serious findings on record at Marquis Newberg, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF551Jan 16, 2026

  Based on interview and record review it was determined the facility failed to ensure the responsible party was involved in decisions related to the resident's day to day activities for 1 of 1 sampled resident (#46) reviewed for resident rights and care planning. This placed residents at risk for their representatives not being informed of the resident's health status. Findings include: Resident 46 was admitted to the facility on 7/2025 with diagnoses including anoxic brain damage (The brain lacks oxygen causing the brain cells to die permanently). A 10/27/25 Quarterly MDS indicated Resident 46 had a BIMS of 7 indicating severe cognitive impairment. […]

• No harm, potential for more than minimal, isolatedF688Jan 16, 2026

  Based on observation, interview and record review it was determined the facility failed to ensure ordered services were obtained to increase ROM for 1 of 2 sampled residents (#46) reviewed for mobility and choices. This placed residents at risk for decreased mobility. Findings include:Resident 46 was admitted to the facility in 7/2025 with diagnoses including hemiplegia (paralysis to one side of the body) and suicidal ideation. A 10/27/25 Quarterly MDS indicated Resident 46 had a BIMS of 7 indicating severe cognitive impairment. A 9/30/25 Orthopedic After Visit Summary indicated Resident 46 had significant tightness and shortening of her/his left knee hamstrings (muscles that help bend the knee, extending the hip and walking). […]

• No harm, potential for more than minimal, isolatedF880Jan 16, 2026

  Based on observation and interview it was determined the facility failed to perform hand hygiene for 1 of 1 sampled resident (#6) reviewed for pressure ulcers. This placed the resident at risk for cross contamination. Findings include:A 11/2022 Wound Care -Level II Policy indicated performing hand hygiene after removing gloves was expected. Resident 6 was admitted to the facility on [DATE] with diagnoses including diabetes.A 1/2026 TAR indicated Resident 6 had a facility acquired pressure ulcer on her/his coccyx (the last bone at the bottom of the spine) and had daily wound care orders. On 1/15/26 at 10:34 AM, Staff 8 (LPN) and Staff 9 (Hospice CNA) entered Resident 6's room and performed wound care. Staff 8 and Staff 9 repositioned Resident 6 onto the right side. […]

• No harm, potential for more than minimal, isolatedF684Sep 26, 2024

  Based on interview and record review it was determined the facility failed to follow physician orders for 1 of 5 sampled residents (#1) reviewed for medications. This placed residents at risk for adverse medication side effects. Findings include: Resident 1 admitted to the facility in 2024 with diagnoses including heart failure. The 9/20/24 progress note by Staff 3 (LPN) indicated Resident 1 received another resident's scheduled medications. Resident 1, her/his family and the physician were notified, and no adverse effects were noted. The resident was placed on alert monitoring. […]

• No harm, potential for more than minimal, isolatedF580Feb 26, 2024

  Based on interview and record review it was determined the facility failed to notify a resident's representative timely of a change of condition for 1 of 3 (#3) sampled residents reviewed for resident rights. This placed residents at risk for delayed treatment. Findings include: Resident 3 admitted to the facility in 7/2023 with diagnoses including Pleural Effusion (a buildup of fluid between the tissues that line the lungs and chest). Resident 3's 7/13/23 facility admission form indicated Witness 1 (family member) was the primary emergency contact. On 2/13/24, a concern was received which alleged Witness 1 was not nofified about a change of condition for Resident 3 on 11/24/23 until after 1:00 PM when the resident exhibited symptoms for several hours prior. […]