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 Piedmont Post Acute Rehab during CMS and state inspections, most recent first.
Unlocked medication and treatment carts were observed unattended on multiple halls, with staff not in view of the carts. The carts contained resident medications and treatment supplies, including insulin and insulin supplies, eye drops, inhalers, prescribed creams and lotions, wound care supplies, nebulizer medications, and other resident items. Staff confirmed the carts were unlocked, and the DNS stated carts were expected to remain locked when not in use.
Failure to assess a cognitively intact resident with depression and ESRD for safe self-administration of meds. Surveyors observed empty Imodium packs and other pill packs in the resident’s room, and a CMA left a tablet in a cup with the resident despite no documented self-administration assessment or directions allowing bedside meds. The resident stated staff often leave meds for later, and the RCM and DNS confirmed the resident had not been assessed.
A resident with CHF and epididymitis was transferred to the hospital for scrotal swelling, but the clinical record did not show that a written bed hold notice was given to the resident or representative. The DNS stated the charge nurse was responsible for providing the bed hold policy at transfer, and the Administrator confirmed the form was not completed.
Failure to provide fingernail care for a resident with DM and ESRD. The resident was cognitively intact, had long pointed fingernails with dark substance under them, and stated assistance was needed because of the DM diagnosis and that nail trimming had not been offered. The chart had no care plan direction for staff or an RN to trim the nails and no documentation that the task was completed; staff stated only an RN could perform the nail care for residents with DM.
Failure to Follow Fall Safety Interventions: A resident with dementia, anxiety disorder, stroke history, and a history of falls was care planned as high fall risk with interventions including no assistive devices at bedside, bed in the lowest position, and a fall mat at bedside. Staff observed the resident in bed with the walker within reach, the bed not in the lowest position, and no fall mat in place, and an RNCM confirmed these were the planned interventions.
A resident with PTSD, moderate depression, and intact cognition did not have PTSD triggers or interventions addressed in the care plan, social services form, or care conference. Staff were unaware of the resident’s triggers, did not complete a behavior assessment related to PTSD, and did not follow up after counseling was initially offered and declined. The resident reported multiple trauma-related triggers, distress during a fire drill when the bedroom door was closed, and anxiety when staff attempted to close the door during care.
Failure to Provide Dental Services: A resident admitted with ESRD and DM2 was documented as cognitively intact with no dental issues, but later was observed with several broken and missing upper front teeth and reported cavities that made chewing challenging and sometimes painful. Staff interviews showed inconsistent understanding of the resident’s oral care needs, with CNAs saying they only reminded the resident to brush after meals and an LPN unaware of missing teeth or cavities; the DNS later found missing, cracked, and decayed teeth that needed to be addressed.
Failure to protect a resident from physical abuse occurred when two cognitively intact residents had an escalating dispute over a loud TV and one resident entered the other’s room. The interaction turned physical, resulting in a bloody nose for the resident with hearing impairment and anticoagulant use. Both residents later described the event as a misunderstanding, but staff confirmed the resident was struck in the face during the altercation.
A facility failed to update a resident's care plan to reflect changes in nutritional and positioning needs. The resident, admitted with a stroke and stage 4 pressure injury, was observed using a regular cup without assistance, contrary to the care plan's requirement for 1:1 assistance and adaptive equipment. Staff interviews revealed a lack of awareness of the care plan, and the hand splint was discontinued due to pain, yet the care plan was not revised.
A facility failed to implement enhanced barrier precautions (EBP) for a resident with a stage 4 pressure injury, as staff did not wear gowns during high-contact care activities. Despite the care plan indicating the need for EBP, staff were observed providing care without the required protective equipment, and some were unable to explain the EBP requirements.
The facility failed to provide sufficient nursing staff to meet resident needs, resulting in delays in care such as showers and toileting. Residents and staff reported challenges due to understaffing, with staffing based on minimum ratios rather than resident acuity. This led to unmet care needs, as confirmed by the facility's administrator and staffing coordinator.
The facility failed to accurately complete the Direct Care Staff Daily Report (DCSDR) postings, which did not reflect the correct number of staff working and their hours for 37 consecutive days. This issue was confirmed by the DNS, who acknowledged the inaccuracies in the staffing reports.
A resident with diabetes and edema was denied assistance with personal hygiene by a CNA, who made a demeaning comment. The charge nurse reassigned the task, and the resident received care. An investigation revealed similar complaints from other residents about the CNA's behavior.
A facility failed to provide a dependent resident with the scheduled showers, resulting in unmet needs and loss of dignity. The resident, with multiple sclerosis and morbid obesity, was supposed to receive showers twice a week but only received five out of nine scheduled showers in a month. Staff confirmed that missed showers were not rescheduled due to staffing issues, and there was no documentation of additional bathing opportunities.
Unlocked Medication and Treatment Carts Left Unattended
Penalty
Summary
The facility failed to ensure medications and biologicals were secured in accordance with its medication cart policy, which required medication carts to be securely locked at all times when out of the nurse’s view. During observation, an unlocked treatment cart was found on the North Hall while the nurse was not in view. The cart contained multiple drawers with resident care items, including insulin and insulin supplies, prescribed creams and lotions, wound care supplies, nebulizer medications and supplies, and shampoos and other treatment supplies. Staff confirmed the cart was unlocked and contained medications and treatment supplies, and the DNS stated it was her expectation that all medication and treatment carts remain locked when not in use. A second unlocked medication cart was observed on the North Hall while the CMA was not in view of the cart. The cart contained multiple drawers with medications, including eye drops, inhalers, nasal sprays, resident prescribed medications, over-the-counter medications, and overflow medications. In another observation, an unlocked treatment cart was found on [NAME] Hall with the nurse not in view, and it also contained insulin and insulin supplies, prescribed creams and lotions, wound care supplies, nebulizer medications and supplies, and shampoos and other treatment supplies. An additional unlocked medication cart was observed near the social services office and room [ROOM NUMBER] with no staff in view; the CMA later acknowledged leaving it unattended and unlocked, and the cart contained resident medications, insulin supplies, eye drops, and inhalers.
Failure to Assess Safe Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident for safe self-administration of medication. Resident 29 was admitted with diagnoses including depression and end stage renal failure, and the 12/17/25 MDS assessed the resident as cognitively intact. During observations on 4/6/26, 4/7/26, and 4/8/26, surveyors found empty six-packs of Imodium on the resident’s dresser and sink counter, as well as empty individual pill packs on the sink counter and floor by the bed. A review of the medical record on 4/8/26 did not show any indication that the resident was safe to self-administer medications. On 4/8/26, a CMA entered the resident’s room, left a white tablet in a small clear plastic pill cup with the resident, and left the room. The resident stated that staff leave this pill for later after meals and often leave other pills for the resident to take later if not taken at the time. The CMA stated some residents had medications left at bedside to self-administer, but confirmed this resident did not have directions allowing bedside medication. The RCM stated staff were expected not to leave medications in a resident’s room unless the resident had a Self-Administration Assessment, and confirmed this resident did not have one. The DNS also acknowledged that residents who wished to self-administer medications were expected to be assessed for safety and that no medication should be left at bedside without an assessment.
Failure to Provide Bed Hold Notice at Hospital Transfer
Penalty
Summary
The facility failed to provide written notice of its bed hold policy for Resident 4 when the resident was transferred to the hospital on 4/3/26 for evaluation and treatment of scrotal swelling. Resident 4 had been admitted in 2/2026 with diagnoses of congestive heart failure and epididymitis. The clinical record showed the provider was notified and orders were received to send the resident to the hospital, but there was no documentation that a written bed hold notice was given to the resident or the resident's representative. On 4/10/26 at 11:30 AM, the DNS stated the charge nurse was responsible for providing the bed hold policy when residents were sent to the hospital and confirmed there was no documentation that Resident 4 received the notice. On 4/10/26 at 11:40 AM, the Administrator also confirmed the bed hold policy was not completed at the time of transfer.
Failure to Provide Fingernail Care
Penalty
Summary
The facility failed to ensure nail care was provided for one resident who was unable to perform the task independently. The resident was admitted with diagnoses including diabetes and end stage renal failure, and the admission MDS assessed the resident as cognitively intact. During observation, the resident was found with long pointed fingernails and dark substance under the nails, and stated that assistance was needed to trim the fingernails because of the diabetes diagnosis, that the resident wanted the nails trimmed, and that assistance had not been offered. Record review showed no directions in the health record for staff to assist with or offer fingernail trimming and no documentation that the fingernails had been completed. Staff interviews confirmed that a CNA did not trim fingernails for residents with diabetes, that only an RN could trim the fingernails for health and safety reasons, and that the resident did not have a plan of care directing a licensed nurse to perform the task or documentation showing the nail trim was completed.
Failure to Follow Fall Safety Interventions
Penalty
Summary
The facility failed to provide care planned safety interventions for Resident 25, who was admitted in 8/2024 with diagnoses of dementia and anxiety disorder. A 3/16/26 Quarterly MDS showed a BIMS of 14, indicating the resident was cognitively intact. A 3/27/26 fall care plan identified the resident as high risk for falls due to acute medical conditions, stroke, and a history of falls, and included interventions of no assistive devices at bedside, bed in the lowest position, and a fall mat at bedside. Random observations from 4/6/26 through 4/9/26 showed Resident 25 in bed with the walker at bedside and within reach, the bed not in the lowest position, and no fall mat in place. On 4/9/26, a CNA and an RN both entered the room, observed the resident in bed, and confirmed the walker was within reach, the bed was not in the lowest position, and a fall mat was not in place. The RNCM confirmed the resident was care planned to have no assistive devices within reach, the bed in the lowest position, and a fall mat at bedside. The DNS stated it was her expectation that staff follow and implement all care planned fall interventions.
Failure to Address PTSD Triggers and Services
Penalty
Summary
The facility failed to identify PTSD triggers and failed to provide treatment and services to address distress related to PTSD for one resident with a documented PTSD diagnosis. The resident was admitted with diagnoses including PTSD, had a BIMS score of 15 indicating cognitive intactness, and the Mood and Behavior CAA indicated psychosocial well-being would be addressed in the care plan with a goal of maintaining current functioning and avoiding complications. However, the 3/18/26 care plan did not address PTSD triggers or interventions, and the social services admission form did not address the resident’s PTSD diagnosis, triggers, or interventions despite a PHQ-2 to 9 score of 15 out of 27 indicating moderate depression. Progress notes documented that the resident was distressed, had increased anxiety, and expressed mental health concerns, and the resident requested to check in with Social Services. The 3/24/26 care conference did not address the PTSD diagnosis, triggers, or interventions. The record also revealed no evidence that the resident refused to discuss the PTSD diagnosis and no follow-up was completed with Social Services. Staff interviews showed multiple staff members were unaware of the PTSD diagnosis or the resident’s triggers, and the RNCM and DNS acknowledged that PTSD triggers and related interventions were not included in the care plan and that the resident had not received PTSD-related services. The resident stated staff did not address the PTSD diagnosis, triggers, or interventions and reported childhood trauma including abandonment, sex trafficking, substance abuse, sexual abuse, and physical abuse. The resident identified triggers including closed doors, windows, curtains, opened bathroom doors, perfumes, supplies with high alcoholic content, chicken pot pies, and tea, and stated closed doors made the resident feel isolated, trapped, and scared. The resident also reported increased anxiety during a fire drill when the bedroom door was closed and described distress lasting for hours afterward. During observation, staff attempted to close the resident’s door while providing care, and the resident stated that having the door and curtain opened was the resident’s preference; staff did not respond and walked away.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide dental services for one resident who was admitted with diagnoses including end stage renal disease and type 2 diabetes. The resident’s admission MDS indicated cognitive intactness and no missing, cracked, or decayed teeth, and the nursing admission assessment documented no dental issues. The care plan later indicated the resident required constant supervision and physical assistance to complete oral hygiene tasks. During observation, the resident was found to have several broken and missing upper front teeth and stated that most of the upper teeth were missing and that cavities made chewing challenging and sometimes painful. The resident also stated staff never examined the inside of the mouth or asked about dental health. Staff interviews showed differing understandings of the resident’s oral care needs: CNAs reported only reminding the resident to brush after meals, one LPN stated the resident was fairly independent and required set-up assistance, and another LPN was unaware of missing teeth or cavities. The DNS later examined the resident’s dentition and stated the resident had missing, cracked, and decayed teeth that needed to be addressed.
Failure to Protect Resident from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse in an incident involving two cognitively intact residents. One resident had diagnoses including dementia, hearing deficit, and use of an anticoagulant medication, while the other resident had diagnoses including diabetes and visual deficit. The event occurred when the resident with hearing impairment entered the other resident’s room because the television was loud and asked for the volume to be turned down. According to the resident-to-resident event assessment, the interaction escalated after the resident in the room told the other resident to leave. The resident who entered the room did not understand the response because of the hearing impairment, and the situation resulted in the resident being struck in the face and sustaining a bloody nose. Staff assessed the injury and found no bruising or swelling, and progress notes documented daily monitoring with no further facial injury, pain, or discomfort. Later interviews showed both residents described the event as a misunderstanding. One resident reported that the other resident became upset and hit him/her in the face with a phone after the resident attempted to grab the phone, while the other resident stated the contact was unintentional and occurred while resisting the attempt to take the phone. Staff also stated the resident who was struck had a history of easy bruising and that the bloody nose occurred in the setting of anticoagulant use.
Failure to Update Care Plan for Resident's Nutritional and Positioning Needs
Penalty
Summary
The facility failed to ensure that care plans were revised to accurately reflect the needs of a resident, specifically in the areas of nutrition and positioning. Resident 37, who was admitted with a stroke and a stage 4 pressure injury, had a care plan indicating the need for 1:1 total assistance for meals and the use of adaptive equipment. However, observations from December 2 to December 5 revealed that the resident was drinking from a regular cup without assistance and no adaptive devices or hand splint were in use. Staff interviews confirmed that the resident's care plan was not updated to reflect the current needs, as the resident no longer required 1:1 assistance or adaptive equipment. Staff members were unaware of the care plan requirements, with one LPN stating that the resident only required supervision and encouragement during meals. Another staff member confirmed that the hand splint was discontinued due to causing pain, yet the care plan was not updated to reflect this change. This oversight placed the resident at risk of receiving unneeded assistance, as the care plan did not accurately represent the resident's current condition and needs.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that enhanced barrier precautions (EBP) were followed for a resident with a complex wound, specifically a stage 4 pressure injury, which placed residents at risk for exposure to infections. The facility's policy required the use of gloves and gowns during high-contact care activities such as transfers, wound care, peri-care, and dressing assistance for residents with catheters and complex wounds. However, during observations, staff members were seen providing care to the resident without donning the required gowns. On multiple occasions, staff members, including a CNA and NAs, assisted the resident with transfers and personal hygiene without wearing gowns, despite the care plan indicating the need for EBP due to the resident's risk of infection. When questioned, some staff members were unable to explain the EBP requirements, and others acknowledged their failure to wear gowns during care. The RNCM confirmed that staff were expected to wear gloves and gowns during these care activities for the resident.
Insufficient Staffing Leads to Unmet Resident Care Needs
Penalty
Summary
The facility failed to ensure sufficient nursing staff was available to meet the needs of its residents, as evidenced by observations, interviews, and record reviews. On the dates reviewed, the facility had a census of 51 residents, with a significant number requiring extensive assistance for daily activities such as mechanical lift transfers, bathing, toileting, and dressing. Additionally, a large portion of the residents had behavioral health needs, were high fall risks, or required bariatric care. Despite these needs, staffing was based on the state's mandatory minimum ratios rather than the acuity needs of the residents, leading to unmet care needs. Multiple residents reported delays in receiving care, such as waiting hours for assistance with showers or toileting. Staff members confirmed the challenges posed by insufficient staffing, noting that when staff called out or did not show up, it was difficult to complete necessary tasks like taking vital signs, providing showers, and assisting with meals. The staffing coordinator and administrator acknowledged the reliance on minimum staffing ratios and the difficulties in maintaining adequate staffing levels, which contributed to the inability to provide timely and appropriate care to residents.
Inaccurate Staffing Reports
Penalty
Summary
The facility failed to ensure the Direct Care Staff Daily Report (DCSDR) postings were thoroughly completed or accurately reflected the number of staff working and their hours worked for all 37 days reviewed. This deficiency was identified through interviews and record reviews, which revealed that the DCSDRs from 8/18/24 through 9/24/24 were incomplete or inaccurate. On 9/25/24, the Director of Nursing Services (DNS) acknowledged that the DCSDRs did not accurately include the hours staff members worked during the reviewed period.
Resident Dignity Compromised by CNA's Refusal to Assist
Penalty
Summary
The facility failed to treat residents in a dignified manner, specifically involving a resident who was denied assistance with personal hygiene by a CNA. The resident, who was cognitively intact and had diagnoses including diabetes and edema, requested help from the CNA after a bowel movement. The CNA refused to assist, making a demeaning comment, and insisted that the resident could manage on their own. The charge nurse intervened and reassigned the task to another CNA, who provided the necessary care. The incident was reported by the resident to the Social Services Director, who conducted interviews with other residents cared for by the same CNA. Two additional residents reported similar issues with the CNA's attitude and inappropriate comments. The facility's administrator confirmed that an investigation revealed the CNA had made rude comments to multiple residents.
Removal Plan
- All staff were educated on resident rights, respect, dignity, abuse and neglect.
- All staff completed written tests on their knowledge of resident rights.
- Dignity and respect audits were completed on residents.
- The quality assurance committee reviewed audits and grievances.
- Staff 19 no longer worked at the facility.
Failure to Provide Scheduled Showers to Dependent Resident
Penalty
Summary
The facility failed to ensure that a dependent resident received the scheduled showers, which placed the resident at risk for unmet needs and loss of dignity. The resident, who was admitted with diagnoses including multiple sclerosis and morbid obesity, was dependent on staff for bathing and was scheduled to receive showers twice a week. However, the resident's bathing logs indicated that only five out of nine scheduled showers were provided during the month of August 2024. There was no documentation of additional bathing opportunities being offered when showers were missed. Interviews with the resident revealed that they had not been showered or had their hair washed for three weeks, and they reported refusing only one shower during that period. Staff members confirmed that missed or refused showers were typically not rescheduled due to staffing issues. The Director of Nursing Services acknowledged a miscommunication regarding the resident's showers, and the Administrator confirmed that there was no evidence of additional showering opportunities being offered when showers were missed or refused.
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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) |
|---|---|---|---|---|
| Fernhill Rehabilitation And Care | 1.7 mi | ★★★★★ | 0 | 0 |
| Porthaven Post Acute | 2.9 mi | ★★★★★ | 9 | 0 |
| Holladay Park Plaza | 3.2 mi | ★★★★★ | 4 | 0 |
| Providence Child Center | 4.1 mi | ★★★★★ | 2 | 0 |
| Laurelhurst Post Acute & Rehabilitation | 4.3 mi | ★★★★★ | 3 | 0 |
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