Marquis Oregon City Post Acute Rehab

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF880Feb 27, 2026

  Based on interview and record review it was determined the facility failed to conduct a risk analysis assessment for potential areas of growth and spread of water-borne pathogens. This placed residents at risk for exposure to water-borne pathogens. Findings include:The Centers for Medicare and Medicaid Services Center for Clinical Standards and Quality/Safety and Oversight Group letter 17-30, revised on 7/6/18, on Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease stated, Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water.A review of the facility's… […]

• No harm, potential for more than minimal, patternF689Feb 27, 2026

  Based on observation, interview, and record review it was determined the facility failed to ensure resident accessible outside space was free from environmental hazards for 1 of 1 memory care outdoor area reviewed for safety and failed to safely transfer 1 of 1 sampled resident (#44) reviewed for ADLs. This placed residents at risk for injury and elopement. Findings include: 1. The facility's undated Friendship House Disclosure Statement revealed:-The physical design of Friendship House allows for wandering both inside and outside of the unit. There are several areas that are inviting to the residents and offer a place to sit and relax or have stimulating objects to investigate. An outside walkway is designed to allow for a safe wandering path. […]

• No harm, potential for more than minimal, patternF584Oct 24, 2024

  Based on observation and interview the facility failed to ensure a clean, home-like environment for 1 of 1 memory care units and 1 of 1 dining halls observed. This placed residents at risk for lessened quality of life. Findings include: On 10/22/24 at 11:58 AM an observation during lunch service in the main dining room revealed the light fixtures had built up debris and dead insects inside eight of eight ceiling lights. On 10/24/24 at 10:45 AM an observation near the exit of the Memory Care Unit revealed debris and dead insects accumulated on two vent covers, and in one ceiling light fixture. […]

• No harm, potential for more than minimal, patternF759Oct 24, 2024

  Based on observation, interview, and record review it was determined the facility had a medication error rate of greater than 5%. The facility's error rate was 18% with six errors in 33 opportunities. This placed residents at risk for inaccurate medication dosage and adverse consequences related to medications. Findings include: 1. Resident 14 admitted to the facility in 11/2019 with diagnoses including dementia. A review of Resident 14's physician orders revealed a 9/25/24 order for acidophilus pectin (probiotic) daily. On 10/23/24 at 9:24 AM Staff 13 (CMA) was observed administering medication to Resident 14. […]

• No harm, potential for more than minimal, patternF761Oct 24, 2024

  Based on observation and interview it was determined the facility failed to ensure medication storage was free of expired biologicals for 1 of 1 medication room reviewed for medication storage. This placed residents at risk for diminished treatment efficacy. Findings include: On [DATE] at 1:52 PM the medication storage refrigerator was observed to have three open vials of aplisol (tuberculosis test solution) with open dates in ,d+[DATE]. Each bottle indicated to discard 30 days after opening. On [DATE] at 1:56 PM Staff 2 (DNS) stated aplisol was to be discarded per the manufacturer's recommendation, 30 days after opening the vial. Staff 2 acknowledged all three vials of aplisol were open for greater than 30 days and needed to be discarded.