Marquis Tualatin Post Acute Rehab

In the surveyor’s words

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

• Immediate jeopardy, patternF880May 22, 2026

  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 failure, determined to be an Immediate Jeopardy situation, placed all residents who required CBG checks at significant risk for bloodborne illness. 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. […]

• Actual harm, isolatedF689Sep 15, 2021

  Based on observation, interview, and record review it was determined the facility failed to ensure staff followed the care plan related to fall safety for 2 of 3 sampled residents (#s 4 and 11) reviewed for falls. Resident 4 was left unattended in the bathroom, fell off the toilet and sustained significant cranial trauma. Findings include: 1. Resident 4 admitted to the facility in 2020 with diagnoses including a neck fracture and repeated falls. A comprehensive care plan dated 9/15/20 indicated Resident 4 required one-person constant supervision and physical assistance during toileting. A Post Fall Assessment initiated on 9/21/20 at 11:45 AM revealed the following: -Resident 4 had an unwitnessed fall in her/his bathroom. […]

• No harm, potential for more than minimal, widespreadF885Feb 2, 2023

  Based on interview and record review it was determined the facility failed to inform residents, resident representatives and families by five PM the next calendar day following the occurrence of a suspected or confirmed COVID-19 infection. This placed residents, resident representatives and families at risk for not being informed of the facility's COVID-19 outbreak status. Findings include: Review of COVID-19 Line Listing tracking records from 11/2022 revealed two staff members were found to be COVID-19 positive on 11/17/22. Review of COVID-19 Updates notification records from 11/2022 revealed the first notification of two positive COVID-19 staff members was not sent out until 11/19/22. […]

• No harm, potential for more than minimal, widespreadF727Aug 12, 2022

  Based on interview and record review it was determined the facility failed to ensure an RN worked as the charge nurse for eight hours a day, seven days a week. This placed residents at risk for unmet assessment needs. Findings include: Direct Care Staff Daily Reports on 6/21/22 and from 7/1/22 through 8/8/22 were reviewed. A RN did not provide direct resident care for seven out of the 40 days reviewed: 6/21/22, 7/4/22, 7/19/22, 7/20/22, 7/21/22, 7/26/22 and 8/7/22. On 8/11/22 at 1:37 PM Staff 10 (Staffing Coordinator) stated he was aware there were multiple days when there was no RN coverage and policy changes to cover those shifts were in process. On 8/12/22 at 11:04 AM Staff 1 (Administrator) acknowledged the requirement to have a RN each day.

• No harm, potential for more than minimal, patternF812May 22, 2026

  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… […]