Marquis Mill Park: Family Not Told of Infection - OR
Nobody called.
Resident 87 arrived at the facility in November 2024, recovering from hip surgery and living with dementia and anxiety. Before the month was out, the family had filled out a Resident Designation Form naming a specific contact, identified in inspection records as Witness 2, to be reached in case of emergency.
On December 3, 2024, a licensed practical nurse documented that Resident 87 had developed a possible infection at the surgical site on the left hip. The nurse notified the facility's nurse practitioner and resident care manager. The nurse practitioner ordered cephalexin, an antibiotic, started that same evening. A physician order was written. The medication appeared in the December medication administration record.
Witness 2 was not called.
Two days passed. On December 5, the resident care manager contacted Resident 87's family about the suspected infection and the antibiotic that had already been started.
When inspectors returned to the facility in April 2026 as part of a complaint investigation, Witness 2 told them directly what had happened. "She/he requested to be notified of any change of condition experienced by Resident 87," the inspection report states, and "was not notified on 12/3/24 when Resident 87's had a suspected infection at the surgical site at her/his left hip."
The LPN who had identified the infection and documented the change of condition told inspectors on April 23 that she had informed the resident care manager and was "not aware if Resident 87's family was notified."
The resident care manager acknowledged the timeline. She confirmed that the suspected infection was identified and treatment started on December 3, but that the emergency contact was not reached until December 5. She told inspectors that her standard practice was to contact family when a resident experiences a change of condition. She did not offer an explanation for the two-day gap.
The facility's director of nursing services was unambiguous when inspectors asked her about it. She said she would consider a potential infection a change of condition requiring notification to an emergency contact, and that Witness 2 should have been contacted on December 3.
The inspection, completed April 24, 2026, cited the facility for failing to notify a resident representative after a change of condition. CMS rated the level of harm as minimal harm or potential for actual harm.
What the citation captures in regulatory language is something more concrete: a person with dementia, recovering from hip surgery, developed a new infection at the surgical site. The family member designated to be her voice, to be informed, to be part of whatever decisions followed, was left out for two days. By the time that call came on December 5, the antibiotic had already been running for 48 hours.
For a resident with dementia, the designated emergency contact isn't a formality. It's the mechanism by which someone who may not be able to fully advocate for herself has another person in the room, even if that person is only in the room by phone. The Resident Designation Form existed precisely because the facility and the family had agreed on that arrangement in November. It was documented. It was on file.
It just wasn't followed.
Marquis Mill Park operates at 1475 SE 100th Avenue in Portland. The complaint inspection was conducted by the Oregon state survey agency on behalf of the Centers for Medicare and Medicaid Services.
Witness 2 learned about the infection two days after it was found, two days after the antibiotic started, and more than sixteen months before an inspector finally asked her what she remembered about it. She remembered exactly.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Marquis Mill Park from 2026-04-24 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 16, 2026 · Our methodology
MARQUIS MILL PARK in PORTLAND, OR was cited for violations during a health inspection on April 24, 2026.
Resident 87 arrived at the facility in November 2024, recovering from hip surgery and living with dementia and anxiety.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.