Marquis Tualatin Post Acute: Boot Left on Chair - OR
The resident, identified in inspection records only as Resident 5, was admitted to Marquis Tualatin Post Acute Rehab in February 2026 after suffering a stroke. By admission, the resident had severe cognitive impairment and already showed range of motion impairment in the lower extremities. A therapy evaluation conducted at admission determined the resident would benefit from a contracture boot on the right foot. The care plan, revised in late April, called for the boot to be placed on the foot for two hours on, two hours off.
Inspectors observed the resident's room on multiple occasions between May 18 and May 21. The boot was on the chair every time. Not once did they find it on the resident's foot.
The resident's family had noticed the same thing. A family member, interviewed just after midnight on May 19, told inspectors the boot was supposed to be applied regularly and that staff had failed to do it. She said she was worried the resident would develop a contracture, a permanent shortening of the muscle that locks a joint in place and cannot be reversed without aggressive intervention, if at all.
Two CNAs interviewed in the days that followed gave answers that did little to suggest anyone on the floor understood what was at stake. The first, interviewed on the afternoon of May 19, knew the resident wore a splint on the right arm to prevent swelling but couldn't provide any information about the contracture boot. The second, interviewed the following morning, knew the resident couldn't move the right side of her body or speak, but said nothing about any plan to prevent further decline.
The rehab director filled in what the CNAs couldn't. On May 20, she told inspectors the boot was prescribed specifically to prevent foot drop and foot inversion, two conditions that can result when a paralyzed foot is left unsupported for extended periods. Foot drop makes it nearly impossible to lift the front part of the foot when walking. Foot inversion turns the sole inward. Both can become permanent. She confirmed the boot needed to be worn consistently.
The director of nursing services, interviewed on the final day of the inspection, said the same thing and went further. She acknowledged directly that staff had not been regularly helping the resident use the boot.
The deficiency was cited at a level of minimal harm or potential for actual harm, a designation that reflects the absence of documented injury at the time of inspection rather than the absence of risk. For a resident who cannot move her right side, cannot speak, and depends entirely on staff to position a prescribed device on her foot, the gap between what the care plan required and what actually happened was not a paperwork problem. The boot was sitting on the chair.
The inspection was completed May 22, 2026. The family member who raised the concern first, sometime after midnight on a Monday, had been watching it happen for longer than that.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Marquis Tualatin Post Acute Rehab from 2026-05-22 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.
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Last verified: October 31, 2026 · Our methodology
MARQUIS TUALATIN POST ACUTE REHAB in TUALATIN, OR was cited for violations during a health inspection on May 22, 2026.
The resident, identified in inspection records only as Resident 5, was admitted to Marquis Tualatin Post Acute Rehab in February 2026 after suffering a stroke.
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.