Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Newberg during CMS and state inspections, most recent first.
A resident with anoxic brain damage and severe cognitive impairment had a court-appointed guardian, but the facility allowed the resident to leave with friends on two occasions without notifying the guardian. Staff acknowledged the guardian was required to be informed when the resident left the building, yet no evidence showed that notification occurred.
A resident with hemiplegia and severe cognitive impairment had documented left knee hamstring tightness and shortening, with orders for aggressive daily therapy, a ROM brace, and contracture training. However, outpatient contracture/orthopedic follow-up was not scheduled, staff were unsure about the appointments, the resident did not perform daily exercises, and the resident did not wear a ROM brace because one was not ordered.
Failure to perform hand hygiene during wound care was observed for a resident with a facility-acquired coccyx pressure ulcer and diabetes. An LPN and a hospice CNA provided wound care, repositioned the resident, changed gloves multiple times, and handled brief care and linen, but hand hygiene was not performed after glove removal or between glove changes. The LPN stated she did not use hand sanitizer because her hands were not visibly soiled and she completed hand hygiene after care, while the Interim DNS stated staff were expected to perform hand hygiene after removing gloves.
An LPN on orientation administered incorrect medications to a resident due to confusion about bed assignments and failure to verify the resident's identity. The resident received medications not prescribed for them, including apixaban and atorvastatin, but experienced no adverse effects. The error was acknowledged by the Corporate RN.
Failure to Notify Guardian of Resident Outings
Penalty
Summary
The facility failed to ensure the resident’s guardian was involved in decisions related to the resident’s day-to-day activities for one resident reviewed for resident rights and care planning. The resident was admitted with anoxic brain damage and had a 10/27/25 Quarterly MDS showing a BIMS score of 7, indicating severe cognitive impairment. A 11/20/25 court order appointed Witness 2 as the resident’s guardian. Progress notes from 11/29/25 through 12/7/25 showed the resident left the facility with a friend on two occasions, and there was no evidence that Witness 2 was notified. On 1/12/26, Witness 2 stated he was frustrated and concerned that the facility allowed the resident to leave with friends and did not tell him. Staff interviews showed that staff knew the resident had impaired cognition and that Witness 2 was the guardian, and staff acknowledged that Witness 2 was required to be notified when the resident left the building, but this did not occur.
Failure to Obtain Ordered Contracture and ROM Services
Penalty
Summary
The facility failed to ensure ordered services were obtained to increase range of motion for one resident with hemiplegia and suicidal ideation. The resident was admitted in 7/2025, and a 10/27/25 Quarterly MDS showed a BIMS of 7, indicating severe cognitive impairment. An orthopedic after-visit summary dated 9/30/25 documented significant tightness and shortening of the left knee hamstrings, noted that the resident required aggressive daily therapy and use of a range of motion brace, and stated that the resident was to start a contracture training program. A 1/12/26 provider note stated the resident was waiting for an outpatient contracture management appointment. During interviews, the health representative stated an outpatient referral had been entered in July 2025 but no updates were received from the facility, and that the resident required an outpatient contracture training program for left leg contractures. The resident stated he/she stopped walking after physical therapy ended and dragged the left foot while walking due to lost muscle tone. Staff interviews indicated the resident did not perform daily exercises, outpatient orthopedic follow-up was unclear, the resident had been referred to outpatient orthopedic services on 8/29/25, staff had hit a dead end and no appointment was scheduled, and the resident did not wear a ROM brace and one was not ordered.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when staff failed to perform hand hygiene during wound care for a resident with a facility-acquired pressure ulcer on the coccyx and a history of diabetes. The resident had daily wound care orders. During observation, an LPN and a hospice CNA entered the resident’s room, repositioned the resident onto the right side, and performed wound care. The LPN removed gloves and put on new gloves multiple times without performing hand hygiene in between glove changes, including after removing the old dressing, after packing the wound with gauze, and after applying a new dressing. The CNA performed personal hygiene, changed the resident’s brief, obtained clean linen from the bathroom, removed linen, and applied new linen without changing gloves. The LPN stated she did not perform hand hygiene because her hands were not visibly soiled and she did not have hand sanitizer, and stated she completed hand hygiene after care rather than between glove changes. The CNA stated she did not touch the dirty linen, but the LPN acknowledged that the CNA did touch the dirty linen. The Interim DNS stated staff were expected to perform hand hygiene after removing gloves.
Medication Administration Error Due to Resident Misidentification
Penalty
Summary
The facility failed to follow physician orders for a resident, resulting in the administration of incorrect medications. A Licensed Practical Nurse (LPN), while on orientation, mistakenly administered another resident's medications to a resident with a diagnosis of heart failure. The medications included apixaban, an anticoagulant, and atorvastatin, a lipid-lowering medication, which were not prescribed for the resident. The error occurred because the LPN was confused about the bed assignments and did not verify the resident's identity before administering the medications. The incident was documented in a Medication Error Report, and the resident, their family, and the physician were notified. The resident was placed on alert monitoring, and no adverse effects were noted in the progress and physician notes following the incident. The Corporate RN acknowledged the error and confirmed that the LPN did not verify the correct resident prior to medication administration.
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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 Newberg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Chehalem Post Acute | 1 mi | ★★★★★ | 3 | 0 |
| Marquis Wilsonville Post Acute Rehab | 8.3 mi | ★★★★★ | 3 | 0 |
| Avamere Rehabilitation Of King City | 9.6 mi | ★★★★★ | 13 | 0 |
| Marquis Tualatin Post Acute Rehab | 9.7 mi | ★★★★★ | 9 | 1 |
| Tigard Rehabilitation And Care | 10.8 mi | ★★★★★ | 19 | 2 |
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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.