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 Wilsonville Post Acute Rehab during CMS and state inspections, most recent first.
Failure to Provide Adequate Nail Care: A resident who was cognitively impaired and dependent on staff for ADLs had dark, thick debris under the fingernails and around the cuticles on both hands over multiple observations. The care plan called for hygiene assistance, but the record lacked documentation of nail care, and staff, including CNAs, an LPN, and an RNCM, acknowledged the nails were dirty and that the resident needed assistance with hand washing and nail care.
A resident with COPD and chronic respiratory failure with hypoxia had an order for supplemental O2 to maintain saturation, but the oxygen concentrator's external foam filter was observed covered in a thick layer of dust on repeated observations. The Interim DNS/Corporate RN acknowledged the condition and stated the filters were expected to be checked and cleaned weekly.
A facility failed to notify the State LTC Ombudsman Office of resident discharges as required by policy. The Business Office Manager stated the discharge list had not been sent for several months, and the Administrator acknowledged the monthly update was missed due to business office staffing changes.
A facility failed to create a comprehensive care plan for a resident with Alzheimer's and vision impairment. The care plan lacked focus on the resident's need for glasses and did not address refusals of personal hygiene care. Staff were unaware of the resident's vision needs, and the care plan did not include strategies for managing care refusals.
A resident with Raynaud's syndrome was not adequately informed or involved in their discharge planning, leading to confusion and stress. Despite being cognitively intact, the resident reported not being included in discussions about their discharge plan, and conflicting information was provided by staff. The facility's documentation lacked evidence of communication with the resident regarding their discharge, and staff admitted to inconsistent documentation practices.
A resident with severe cognitive impairment and Alzheimer's disease did not receive a bath or shower for 27 days, despite requiring moderate staff assistance for personal hygiene and grooming. Staff acknowledged the resident frequently refused care, but there was no documentation of refusals or alternative care attempts in the health record. The DNS confirmed the lack of care and stated that the approach and plan of care should be modified if a resident consistently refuses care.
A facility failed to provide necessary vision services for a resident with macular degeneration. Despite the resident's need for glasses and a new prescription, as documented in their records, there was no follow-up to arrange a vision assessment or appointment. Observations confirmed the resident was not wearing glasses, and staff acknowledged the oversight.
A facility failed to ensure pharmacy recommendations were followed for a resident, risking adverse medication reactions. The resident, with depression and hypotension, had a pharmacist review their medication regimen. Recommendations to discontinue PRN haloperidol and extend PRN lorazepam were made, but no provider response was recorded until a month later, confirmed by the Resident Care Manager.
A resident with a history of stroke and intestinal obstruction was prescribed both loperamide and Miralax, despite orders to hold Miralax for loose stools. The resident received Miralax daily, even on days with documented loose stools, leading to unnecessary medication use. The DNS acknowledged the oversight.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to provide adequate nail care for a resident who was unable to perform activities of daily living independently. The resident was admitted with diagnoses including a fracture of the left leg. The care plan directed that the resident’s hygiene needs would be met and that the resident required constant supervision and physical assistance from staff with hand washing. The admission MDS indicated the resident was cognitively impaired and required substantial to maximum staff assistance for personal hygiene. Observations made over multiple days showed the resident’s fingernails and cuticles on both hands were coated in dark, black thick debris collected underneath the nails and built up around the cuticles. The health record did not include documented evidence specific to the provision of nail care. The resident was unable to provide information about personal hygiene abilities and nail care preferences. The spouse stated the nails appeared to contain blood, feces, or food and said the condition bothered her, noting the nails looked the same on a prior visit. Staff stated the resident was dependent on staff for ADLs, including hygiene care, that CNAs were responsible for hand washing and ensuring fingernails were clean, and that staff should notice dirty fingernails and provide appropriate care. An RNCM observed the nails and cuticles and stated they were dirty, while the Interim DNS/Corporate RN was informed of the observations and acknowledged missed opportunities to notice and provide nail care.
Oxygen concentrator filter not maintained
Penalty
Summary
The facility failed to ensure resident respiratory equipment was maintained for one of two sampled residents reviewed for respiratory care. Resident 44 was admitted with diagnoses including chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia, and had a physician order dated 3/30/26 requiring supplemental oxygen use to maintain oxygen saturation. On 4/6/26 at 1:49 PM and again on 4/7/26 at 11:30 AM, the resident's oxygen concentrator was observed with an external foam filter covered in a thick layer of dust. On 4/7/26 at 3:30 PM, Staff 3, the Interim DNS/Corporate RN, acknowledged that Resident 44's concentrator foam filter was covered in a thick layer of dust and stated she expected the filters to be checked and cleaned weekly.
Failure to Notify State Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to ensure the State Long Term Care Ombudsman Office was notified of resident discharges as required. The facility’s undated Notice Transfer Discharge Policy & Procedure stated that the business office would notify the state ombudsman office of all transfers and discharges monthly, or by the cadence defined by the ombudsman office. During interview, the Business Office Manager stated that a list of discharged residents had not been sent to the state ombudsman office since 10/2025. The Administrator stated the facility’s process was to send a monthly update of discharged residents to the state ombudsman office and acknowledged that, due to business office staffing changes, the list of residents had not been sent.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for a resident with Alzheimer's disease and macular degeneration. The resident's admission MDS indicated the importance of wearing glasses for reading, yet the care plan did not include any focus, goals, or interventions related to the resident's vision needs. Staff members, including CNAs and an RN, were unaware of the resident's need for glasses, and the social services staff member responsible for building the care plan acknowledged the omission. Additionally, the resident required moderate assistance for personal hygiene and grooming, as noted in the admission MDS. Despite documented refusals of care, the care plan did not include person-centered interventions to address these refusals. The resident consistently refused bathing opportunities, as recorded in the Bath/Shower Task Flowsheet, yet the care plan lacked strategies to manage these refusals. The LPN Resident Care Manager confirmed that the care plan did not reflect the resident's refusal of hygiene and grooming care.
Failure to Involve Resident in Discharge Planning
Penalty
Summary
The facility failed to ensure that a resident was involved and informed of their discharge plan, which was a deficiency identified during the survey. The resident, who was admitted with Raynaud's syndrome and was cognitively intact, expressed that they were not included in discussions about their discharge plan. The discharge care plan created by the social services staff indicated an anticipated discharge to a higher level of care, but lacked detailed information. Although a care conference was held to review the discharge plan, the resident reported feeling uninformed and confused about the discharge date and details, as conflicting information was provided by various staff members. The resident's health record lacked documentation of communication regarding the discharge plan after the care conference. Staff members admitted to having informal conversations with the resident about the discharge plan, but these were not documented. The staff responsible for discharge planning acknowledged the inconsistency in documentation and the absence of records indicating that the resident was kept informed about their discharge plan. This lack of documentation and communication led to the resident feeling stressed and uninformed about their discharge from the facility.
Failure to Provide Adequate Bathing and Grooming
Penalty
Summary
The facility failed to provide adequate bathing and grooming for a resident with severe cognitive impairment, Alzheimer's disease, restlessness, and agitation. The resident required moderate staff assistance for personal hygiene and grooming, as indicated in their care plan. However, the resident did not receive a bath or shower for 27 days, as documented in the Bath/Shower Task Flowsheet. Observations noted the resident had long, unkempt facial hair, and family members confirmed the resident was usually clean-shaven. Staff members, including CNAs and an RN, acknowledged the resident required assistance and frequently refused care. The CNAs stated that if a resident refused care, they would attempt to redirect and offer care multiple times, reporting refusals to the nurse if unsuccessful. However, the RN was unaware of any refusals, and the resident's health record lacked documentation of refusals, alert charting, or alternative care attempts. The DNS acknowledged the resident did not receive necessary care and stated that attempts should be made to modify the approach and plan of care if a resident consistently refuses care.
Failure to Provide Vision Services for Resident with Macular Degeneration
Penalty
Summary
The facility failed to ensure that a resident with macular degeneration received necessary vision services. The resident was admitted in September 2024 and had a documented need for glasses, as indicated in the Admission MDS and the Vision CAA completed by Social Services. The resident's health record showed no evidence that the facility facilitated vision services to assess and provide the appropriate prescription glasses. Despite the resident's expressed need for a new prescription, there was no follow-up to arrange a vision assessment or appointment. Observations on multiple occasions confirmed the resident was not wearing glasses, and the resident was unable to answer questions about their use. Staff acknowledged the oversight in not following up on the resident's vision needs.
Failure to Follow Up on Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were followed up on for a resident reviewed for medications, placing them at risk for adverse medication reactions. The resident, admitted in February 2024 with diagnoses including depression and hypotension, had their medication regimen reviewed monthly by a pharmacist. On November 4, 2024, the pharmacist recommended discontinuing PRN haloperidol after 14 days unless a new order was written following a direct examination and documentation. Additionally, the pharmacist advised extending PRN lorazepam beyond 14 days with a rationale for its necessity as the resident transitioned towards end-of-life care, with a re-evaluation after six months. However, there was no response from the provider regarding these recommendations in the resident's health care record until December 5, 2024. This delay in response was confirmed by the Resident Care Manager on December 19, 2024.
Failure to Prevent Unnecessary Bowel Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically bowel medications. A resident, who was admitted with a history of stroke and a recent hospital procedure for intestinal obstruction, was prescribed loperamide, an antidiarrheal medication, and Miralax, a laxative. The hospital orders specified that Miralax should be held if the resident experienced loose stools. Despite this, the resident received Miralax daily from April 17 to April 29, 2024, even on days when they had loose or watery stools, as documented on multiple occasions. The Director of Nursing Services acknowledged that the resident received both an antidiarrheal and a laxative, which contributed to the occurrence of loose stools on the identified dates.
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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 Wilsonville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marquis Hope Village | 5.1 mi | ★★★★★ | 0 | 0 |
| Marquis Tualatin Post Acute Rehab | 5.5 mi | ★★★★★ | 9 | 1 |
| Rose Linn Care Center | 6.6 mi | ★★★★★ | 12 | 0 |
| Avamere Rehabilitation Of King City | 7.3 mi | ★★★★★ | 13 | 0 |
| Marquis Newberg | 8.3 mi | ★★★★★ | 6 | 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.