Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Forest Grove Post Acute Rehab during CMS and state inspections, most recent first.
An LPN gave one resident another resident’s methadone after failing to properly confirm identity and relying on a CNA’s direction in the dining room. The resident had orders for crushed meds and a history of confusion, but received the wrong medication and later developed somnolence, slurred speech, nausea/vomiting, and bradycardia, requiring ER transfer and hospital monitoring for accidental methadone overdose.
An LPN gave one resident another resident’s liquid methadone after relying on a CNA’s gesture and not properly confirming identity. The resident, who had COPD, DM, and dementia, later became somnolent with slurred speech, N/V, and bradycardia, required Narcan and Zofran, and was transferred to the ED for monitoring after an accidental methadone overdose.
The facility failed to ensure proper medication storage and labeling, with an undated vial of tuberculin and an open insulin lispro pen found without open dates. Additionally, medication room refrigerator temperature logs were incomplete, and temperatures exceeded the required range, risking the efficacy of stored medications.
The facility failed to follow proper infection control practices in the laundry room. Housekeeping staff left wet laundry in the washing machine overnight and transferred it to the dryer the next morning without rewashing, contrary to CDC guidelines. The administrator was unaware of any policy regarding this issue.
A facility failed to maintain a resident's oxygen concentrator, leading to a deficiency in respiratory care. The resident, with COPD, used the concentrator nightly. Facility policy required weekly cleaning of filters, but one filter was found dusty. Staff responsible was unaware of the second filter, leading to inadequate maintenance.
Medication Error During Resident Identification
Penalty
Summary
The facility failed to ensure staff followed professional standards during medication administration for one licensed nurse involved in a significant medication error. Resident 49, who was admitted with diagnoses including COPD and diabetes, had orders for medications to be crushed in applesauce. The resident also had a history of confusion noted in the record, and staff had previously provided education to the nurse about where to find the crushed-medication orders after the resident had choked on whole medications. On 11/3/25, the nurse administered methadone 40 mg intended for another resident to Resident 49 after asking a CNA in the dining room who the other resident was and relying on the direction indicated by the CNA. The nurse later documented that it was unclear which patient had been pointed out and that the resident seemed to be in that direction. Staff later reported that the nurse did not confirm the resident’s identity before giving the medication. Another nurse observed the medication cup labeled with the other resident’s room number and stated the incorrect resident had already received the medication. After the medication error, Resident 49 became somnolent and had slurred speech, then developed nausea and vomiting. The resident’s vital signs showed elevated blood pressure and a slow pulse, and the physician ordered Narcan and Zofran. The resident continued to have symptoms, including an irregular heart rate with pauses, and was transferred to the emergency room for monitoring and evaluation. Hospital records identified the primary diagnosis as accidental methadone overdose and bradycardia.
Wrong-Resident Methadone Administration
Penalty
Summary
The facility failed to ensure a resident was free from a significant medication error when an LPN administered another resident’s methadone to the wrong resident. Resident 49, who had diagnoses including COPD, diabetes, and dementia, was given Resident 41’s liquid methadone 40 mg after the nurse relied on a CNA’s gesture in the dining room and did not properly confirm the resident’s identity before giving the medication. The nurse later stated the resident was not in the room, asked who Resident 49 was, and then administered the medication after the resident answered yes when asked if he/she was Resident 41. After the medication was given, Resident 49 developed somnolence, slurred speech, nausea, vomiting, and later bradycardia with an irregular pulse and pauses noted on apical assessment. The physician was notified of the change in condition and ordered Narcan and Zofran, and the resident was closely monitored. When the resident’s condition did not improve and heart rate remained low, the physician ordered transfer to the emergency room for evaluation and monitoring. Facility records and hospital documentation confirmed that Resident 49 was hospitalized for accidental methadone overdose and bradycardia after receiving 40 mg of methadone intended for another resident. The hospital noted poison control recommended monitoring because of the risk for arrhythmias, bradycardia, nausea, and vomiting, and the resident continued to have intermittent bradycardia and atrial fibrillation during observation. The facility investigation determined the nurse did not follow proper resident identification procedures and failed to confirm the resident’s identity before medication administration.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage and labeling, which was identified during an observation, interview, and record review. An open, undated vial of tuberculin was found in the medication room refrigerator, contrary to the manufacturer's instructions that require discarding the medication 30 days after opening. Staff acknowledged the vial was not labeled with the date it was opened, and the Director of Nursing Services (DNS) confirmed that the expectation was for staff to label tuberculin with an open date. Additionally, an open insulin lispro pen was found in the East Hall treatment cart without an open date, despite the manufacturer's instructions to discard it 28 days after opening. Staff again acknowledged the lack of labeling, and the DNS reiterated the expectation for labeling insulin with open dates. The facility also failed to maintain appropriate medication storage temperatures. The medication room refrigerator temperature logs for October and November 2024 showed missing temperature recordings on several dates, and the DNS acknowledged this lapse, stating that the expectation was for staff to log temperatures twice daily. Furthermore, the logs indicated that the refrigerator temperatures exceeded the required range of 36 F to 46 F on multiple occasions, reaching 48 F on specific dates. The DNS confirmed that the refrigerator contained vaccines and insulin, and the expectation was for the refrigerator to be kept within the specified temperature range.
Inadequate Laundry Infection Control
Penalty
Summary
The facility failed to maintain proper infection control practices in the laundry room, as observed during a survey. Staff 11, a housekeeping employee, stated that when wet laundry was not completed in the washing machine by the end of her shift, she left it in the machine overnight. The next morning, she or other housekeeping staff would transfer the wet laundry to the dryer without rewashing it. This practice was contrary to the CDC guidelines, which specify that damp laundry should not be left in machines overnight. During the survey, damp clothing protectors were observed in the washing machine after housekeeping staff had left for the day. The facility administrator was unaware of any policy regarding damp laundry being left in the washing machine overnight.
Failure to Maintain Resident's Respiratory Equipment
Penalty
Summary
The facility failed to maintain respiratory equipment for a resident with Chronic Obstructive Pulmonary Disorder, leading to a deficiency in respiratory care. The facility's policy required weekly cleaning of oxygen concentrator filters. However, during an observation, one of the two external foam filters on the resident's oxygen concentrator was found to have a thick layer of dust, while the other appeared clean. The resident, who was cognitively intact, used the oxygen concentrator nightly and as needed. Staff 3, responsible for cleaning the filters, was unaware of the presence of two filters and had only cleaned one, as confirmed by her statement and the task log. Staff 2 later acknowledged the dirty condition of the left-side foam filter.
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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 Forest Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Forest Grove Post Acute | 0.5 mi | ★★★★★ | 0 | 0 |
| Avamere Rehabilitation Of Hillsboro | 5.3 mi | ★★★★★ | 20 | 1 |
| Hillsboro Health & Rehabilitation Center | 6.4 mi | ★★★★★ | 3 | 0 |
| Maryville | 12.8 mi | ★★★★★ | 1 | 0 |
| Beaverton Post Acute Care Of Cascadia | 14.3 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.