Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Marquis Centennial Post Acute Rehab during CMS and state inspections, most recent first.
A resident with a hip fracture and anxiety reported to social services that a CNA had been rough, told the resident to take themself to the bathroom, and instructed them not to get out of bed until a specified early morning time. The allegation was received by facility staff in the late afternoon, but the incident report was not submitted to the State Agency until the following day, exceeding the required 2-hour reporting timeframe acknowledged by the DNS. The deficiency concerns this untimely reporting of an abuse allegation, despite the CNA’s denial of any abuse.
Surveyors found widespread environmental deficiencies, including dirty and dusty fixtures, vents, and fans in common areas, as well as unkept and unsanitary shower rooms with mold-like substances, rust, and damaged fixtures. A resident with pneumonia expressed concerns about the shower room's cleanliness and safety, and another resident was bothered by scratches and missing paint in their room. Facility staff acknowledged these issues during the survey.
Staff failed to label and discard food items appropriately in a unit refrigerator, leaving undated and expired food present. Housekeeping staff were unaware of food storage policies, and scheduled cleaning was missed. In the kitchen, dietary aides stored an ice scoop directly in the ice and used it without gloves, contrary to expected procedures. These actions did not meet professional standards for food safety.
Staff did not follow infection control protocols for two residents, including not using PPE during wound care for a resident with a draining leg wound and allowing another resident's urinary catheter tubing to rest on the floor. These actions were inconsistent with facility policy and CDC guidelines for enhanced barrier precautions.
A resident with dysphagia and cognitive impairment was provided with thin liquids instead of the prescribed mildly thickened liquids due to the care plan not reflecting the physician's order. Multiple CNAs were unaware of the dietary requirement, and the RNCM confirmed the care plan omission, resulting in the resident receiving inappropriate fluids.
A resident with anxiety disorder and malnutrition reported a broken bed foot board that remained unrepaired for several days. Despite two CNAs being aware of the issue and attempting to reinsert the foot board, maintenance was not notified, and no repair request was submitted. The Maintenance Director stated staff are expected to report such issues electronically.
The facility failed to follow care plans and provide adequate supervision, resulting in falls and injuries for two residents. One resident sustained serious injuries after a CNA allowed them to walk to the bathroom with only a cane, contrary to their care plan. Another resident, with a history of falls, was left unsupervised while awake, leading to multiple falls.
The facility failed to provide a timely Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) for a resident with dementia and emphysema, who had impaired memory and decision-making skills. The notice was given on the last covered day of Medicare Part A services instead of the required 48-hour notice, placing the resident at risk for unknown financial liabilities.
The facility failed to conduct a new and accurate Level I PASARR for a resident with serious mental illness diagnoses and did not complete a referral for a Level II PASARR. The resident exhibited significant behavioral issues, and the administrator acknowledged the incorrect coding and the need for a referral.
The facility failed to develop a comprehensive care plan for a resident with moderate cognitive impairment and a language barrier. Staff were unaware of a communication binder available to assist in communication, leading to ineffective communication and unmet care needs.
The facility failed to follow physician orders for a resident with heart failure, missing multiple days of required daily weights in April 2024. Staff interviews confirmed that the resident rarely refused to be weighed, but documentation and communication lapses led to the deficiency.
The facility failed to perform post-dialysis assessments on a resident with end-stage renal disease. Despite a physician's order, these assessments were not completed on multiple dates. The resident reported that their vitals and port site were often not checked after dialysis. Staff confirmed that required assessments were not performed or documented.
The facility failed to protect residents from physical abuse, involving multiple incidents where one resident pushed another, causing minor injuries, and another resident physically assaulted a fellow resident in the dining room. Additionally, a resident with severe cognitive impairment punched another resident in the face while she/he was resting in bed. Staff interviews confirmed a history of aggressive behavior and poor safety awareness among the involved residents.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to timely report an allegation of abuse to the State Agency after a resident reported that a CNA had been rough and verbally directive with them. The resident, who had been admitted with diagnoses including a hip fracture and anxiety, stated that the CNA was “kind of rough,” told the resident to take themself to the bathroom, and instructed the resident not to get out of bed until 6:00 AM. The resident reported this allegation of abuse involving the CNA to the social services staff member at 4:00 PM on 1/29/26. According to the facility’s investigation documentation, the allegation was received by staff at 4:00 PM on 1/29/26, and the Facility Reported Incident form was not received by the State Agency until 2:13 PM on 1/30/26. The DNS acknowledged that the facility became aware of the allegation at 4:00 PM on 1/29/26 and that it should have been reported to the State Agency within two hours but was not. The CNA denied abusing the resident or any resident, but the deficiency centers on the delay in reporting the allegation to the State Agency within the required timeframe.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's physical environment, including a lack of maintenance and cleanliness in common areas and resident spaces. In the dining room, all hanging light fixtures contained dead insects, portable fans were visibly dusty and blowing air toward residents, and floor vents were coated in thick dust, debris, and cobwebs. In the kitchen, a dirty floor fan was operating and blowing air across both clean and dirty areas, including sanitized food containers. A ceiling vent in a hallway was also found with significant dust and cobweb buildup. Facility staff, including the Administrator and Maintenance Director, acknowledged these concerns during the survey. A resident with a recent admission for pneumonia reported concerns about the cleanliness and safety of the shower room, specifically noting a black substance on the floor that staff attempted to clean without success. Observations confirmed the shower room was unkept, with mold-like substances, rust, peeling tiles, a loose drain lid, and a dirty fan. Clean linens were stored on a rusty shelf, and the water handle was loose and difficult to adjust. Another resident's room was observed with scratches and missing paint on the wall, which the resident found bothersome. Staff acknowledged these environmental issues required attention.
Improper Food Labeling and Unsafe Ice Handling Practices
Penalty
Summary
Facility staff failed to ensure proper labeling and timely disposal of food items in one of two unit refrigerators. Observations revealed several undated containers of food, including a meal with a ticket dated ten days prior, and other containers of spaghetti and rice with mixed vegetables that were not labeled. Interviews with staff indicated that housekeeping was responsible for cleaning and discarding old or undated food items every 72 hours, but the designated housekeeper was away, and the last cleaning had occurred a week prior. Housekeeping staff were unaware of the facility's food storage policies, and maintenance staff confirmed the cleaning schedule was not followed as expected. Additionally, during a kitchen tour and meal service observation, a covered container of ice was found with the ice scoop stored inside, directly on the ice. Dietary aides were observed using the scoop without gloves and returning it to the ice container after use. Staff interviews revealed a lack of awareness of proper procedures for storing the ice scoop, and the dietary manager confirmed that staff were expected to store the scoop separately from the ice. These practices did not align with professional standards for safe food storage and handling.
Failure to Implement Infection Control Practices for Wound and Catheter Care
Penalty
Summary
The facility failed to implement proper infection prevention and control practices for two residents with specific care needs. For one resident with a facility-acquired wound behind the left calf, staff did not follow enhanced barrier precautions (EBP) as required by facility policy and CDC guidelines. Despite the presence of a wound with fluid and drainage, staff did not don personal protective equipment (PPE) during high-contact activities such as bathing and wound care. Additionally, there were no signs posted outside the resident's room to indicate the need for EBP, and multiple staff members stated they did not use PPE because they believed the wound was not infected or the drainage was minimal. For another resident with an indwelling urinary catheter, the catheter tubing was repeatedly observed on the floor while the resident was in the activity room. Staff members acknowledged that the tubing should not touch the floor and confirmed the observation, but failed to ensure proper catheter care practices were followed. These lapses in infection control placed both residents at increased risk for infection.
Failure to Implement Physician Order for Thickened Liquids
Penalty
Summary
A deficiency occurred when the facility failed to implement a physician's order for mildly thickened liquids for a resident with dysphagia. The resident, who was cognitively impaired and required mildly thickened liquids per hospital discharge orders, did not have this requirement reflected in the nutrition care plan. Multiple observations showed the resident had access to thin liquids at the bedside, and several CNAs confirmed they were unaware of the thickened liquid order. The RN Case Manager acknowledged that the care plan did not include the physician's order, which led to staff providing thin liquids instead of the prescribed consistency.
Failure to Repair Broken Bed Foot Board
Penalty
Summary
A deficiency was identified when a resident, admitted with generalized anxiety disorder and malnutrition and noted to be cognitively intact, reported that the foot board of their bed was broken and had not been repaired. The issue was first noticed by the resident, who stated the foot board had been broken for several days. Observations confirmed that the foot board was unsecured and could be dislodged when pressure was applied. Two nursing assistants were aware of the broken foot board, having observed it was not secured and attempting to reinsert it, but neither notified maintenance. A review of maintenance work orders showed no request had been submitted for repair, and the Maintenance Director confirmed that staff were expected to report such issues electronically during their shift.
Failure to Follow Care Plans and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure staff followed the care plan related to fall safety and provide sufficient supervision to prevent a fall for two residents. Resident 306, who was admitted with a right leg fracture and right shoulder fracture, required extensive assistance from two or more staff to transfer on and off the toilet. However, on 5/7/23, an agency CNA responded alone to Resident 306's call for assistance and allowed the resident to walk to the bathroom with only a cane, contrary to the care plan. This resulted in Resident 306 falling and sustaining serious injuries, including a left shoulder fracture, a rib fracture, and a periprosthetic fracture involving the left greater trochanter. The facility's internal investigation confirmed that the CNA did not follow the care plan at the time of the fall. Resident 47, admitted with dementia and a history of falls, was also not provided with adequate supervision. The resident's care plan indicated that they should not be left unsupervised in their room while awake due to the risk of self-transfer attempts. Despite this, the resident experienced multiple falls, including one on 4/13/24, where the CNA failed to provide necessary details about care provided prior to the fall. Additionally, on 4/30/24, a CNA left Resident 47 alone in their room while awake, leading to the resident attempting to transfer themselves out of bed. The pressure-sensitive call light did not activate, and the resident was found attempting to stand up independently. Both incidents highlight a failure to adhere to care plans and provide adequate supervision, resulting in falls and injuries. Staff interviews revealed that CNAs were expected to consult care plans and perform frequent checks on high-risk residents, but these protocols were not consistently followed. The deficiencies in supervision and adherence to care plans directly contributed to the accidents involving Residents 306 and 47.
Failure to Provide Timely SNF ABN Notice
Penalty
Summary
The facility failed to provide a written Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) in a timely manner for a resident reviewed for Beneficiary Protection Notification. The resident, who was admitted with diagnoses including dementia and emphysema, had impaired short- and long-term memory and moderately impaired decision-making skills. The resident's last covered day of Medicare Part A services was on 4/1/24, and the facility provided the Notice of Medicare Non-Coverage on the same day. However, the facility should have given a 48-hour notice to inform the resident of the change, as stated by the Administrator. This failure placed the resident at risk for unknown financial liabilities.
Failure to Conduct Accurate PASARR and Referral for Behavioral Services
Penalty
Summary
The facility failed to conduct a new and accurate Level I PASARR when it became aware of indicators of a serious mental illness diagnosis for a resident. The resident, who was admitted in June 2023, had multiple diagnoses including Psychotic Disorder with delusions, Delusional Disorder, Dementia with behaviors, PTSD, Major Depressive Disorder, and anxiety. Despite these diagnoses and documented behavioral concerns such as delusions, physical and verbal aggression, socially inappropriate behaviors, and a history of suicidal behavior, the facility did not complete a correct Level I PASARR or make a referral for a Level II PASARR for behavioral services. Observations and record reviews revealed that the resident exhibited significant behavioral issues, including slamming doors, yelling at others, and making negative statements on multiple occasions. The resident was also observed to self-isolate in their room. The facility's administrator acknowledged that the Level I PASARR was coded incorrectly and that a referral for a Level II PASARR should have been initiated given the resident's diagnoses and behaviors. No additional information was provided to rectify the situation.
Failure to Develop Comprehensive Care Plan for Resident with Language Barrier
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for a resident with moderate cognitive impairment and a language barrier. The resident, who primarily spoke Chinese/Taiwanese/Cantonese, was observed struggling to communicate with staff, who were unaware of the available communication aids. Specifically, a CNA was seen attempting to understand the resident through trial and error, and was unaware of a communication binder with pictures that could assist in communication. This binder was found in the resident's room but was not included in the care plan, leading to ineffective communication and unmet care needs. Further interviews revealed that the staff, including the CNA and RNCM, were not informed about the communication binder, and it was not documented in the resident's care plan. The SSD and Administrator both confirmed that communication aides should be included in care plans to ensure staff are aware of and use them. The lack of inclusion of the communication binder in the care plan resulted in staff being unaware of its existence and not utilizing it to aid in communication with the resident.
Failure to Follow Physician Orders for Daily Weights
Penalty
Summary
The facility failed to follow physician orders for a resident diagnosed with heart failure, who was admitted in June 2023. The physician's orders required daily weights to be obtained for the resident and to notify the physician if the resident gained three pounds in 24 hours or five pounds in a week. However, a review of the resident's weight summary for April 2024 revealed multiple days without recorded weights, specifically on 4/2, 4/3, 4/4, 4/5, 4/8, 4/9, 4/12, 4/17, 4/18, 4/19, 4/20, 4/26, and 4/30. This failure to document weights as ordered placed the resident at risk for unmet needs related to their heart failure condition. Interviews with staff confirmed the deficiency. A CNA stated that the resident was to be weighed daily and rarely refused. An LPN confirmed that the resident was weighed daily due to heart failure and that nurses were expected to document reasons for any missed weights in the resident's progress notes. However, the LPN acknowledged that CNAs did not always inform her when weights were not obtained, leading to missing documentation. The Director of Nursing Services also confirmed that the resident was cooperative with being weighed and that nurses were expected to notify the physician if weights were not obtained, which did not occur as required.
Failure to Perform Post-Dialysis Assessments
Penalty
Summary
The facility failed to perform post-dialysis assessments on a resident with end-stage renal disease. Despite a physician's order requiring nursing staff to assess the resident's vital signs and write a progress note upon their return from dialysis, these assessments were not completed on multiple dates in April 2024. The resident reported that their vitals and port site were often not checked after dialysis. Staff confirmed that post-dialysis assessments, which should include checking respiratory rate, heart rate, blood pressure, and the port site, were not performed or documented as required.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect the residents' right to be free from physical abuse by another resident, affecting two of the five sampled residents. Resident 34, who was admitted with a history of traumatic brain injury and severe cognitive impairment, was involved in multiple incidents with Resident 47, who had dementia with psychotic disturbance and PTSD. On one occasion, Resident 47 pushed Resident 34, causing her/him to fall and sustain minor injuries. Despite staff efforts to keep the residents apart, Resident 34 went outside to the courtyard where Resident 47 was visiting with her/his spouse, leading to the altercation. Staff interviews confirmed that Resident 47 had a history of aggressive behavior and poor safety awareness, which contributed to the incident. In another incident, Resident 47 physically assaulted Resident 34 in the dining room by grabbing her/him around the neck and face. This occurred after Resident 47 accused Resident 34 of being a thief, possibly confusing the voice on the television for Resident 34. Staff members intervened immediately, but Resident 34 sustained red marks on her/his neck and forehead. Staff interviews revealed that Resident 47 had been in a bad mood that day and had a history of aggressive behavior towards other residents. Additionally, Resident 43, who had severe cognitive impairment, punched Resident 29 in the face while she/he was resting in bed. The facility was not aware of the incident until the following day when swelling and discoloration were observed on Resident 29's upper lip. Staff interviews and written statements confirmed that Resident 43 had a history of behavioral disturbances and that the incident was not immediately reported or addressed. The facility acknowledged the findings of the investigation and the failure to protect residents from abuse.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Portland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gresham Post Acute Care And Rehabilitation | 1.9 mi | ★★★★★ | 26 | 0 |
| Village Health Care | 1.9 mi | ★★★★★ | 12 | 0 |
| Village Manor Of Cascadia | 2.4 mi | ★★★★★ | 1 | 0 |
| Fairlawn Health And Rehab Of Cascadia | 3 mi | ★★★★★ | 4 | 0 |
| Avalon Care Center - Portland | 3.7 mi | ★★★★★ | 4 | 0 |
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