Marquis Tualatin Post Acute Rehab: Glucometer Failure - OR
The device at the center of the finding was a 2017 Evencare G2 glucometer, used to draw and test blood samples from residents. Because it contacts blood, it moves from resident to resident carrying that risk with it. The manufacturer's own manual required staff to wipe the device with an approved disinfectant wipe and leave it wet for two minutes before the next use. The facility's own undated disinfection policy said the same thing: EPA-approved disinfectant wipes, after every individual patient use.
On May 19, at 12:12 in the afternoon, an inspector watched a staff member identified in the report as Staff 6 obtain a blood glucose reading from Resident 31. Staff 6 then walked back to the medication cart, pulled out an alcohol pad, wiped down the glucometer, and put it away.
An alcohol pad is not an EPA-approved disinfecting wipe. The two are not interchangeable.
When asked about it, Staff 6 said she always cleaned the glucometer that way. She believed other staff did the same.
That detail is the most significant line in the inspection report. It suggests the wrong practice wasn't a one-time lapse or a moment of distraction. It was routine, normalized, unremarked upon, and apparently undetected by anyone in a supervisory position until an outside inspector watched it happen.
Three hours and eighteen minutes after the observation, inspectors spoke with Staff 2, identified as the director of nursing. She said she expected staff to use EPA-approved disinfecting wipes after every resident use. She acknowledged, when presented with what inspectors had seen, that alcohol pad wipes were not sufficient for the job.
The gap between what the director of nursing expected and what was actually happening at the medication cart is the story here. The policy existed. The manufacturer's instructions existed. The expectation existed. None of it translated into what Staff 6's hands did when she finished drawing blood from Resident 31.
Glucometers are among the most consistently flagged infection control risks in nursing home settings. When a device that pierces skin and contacts blood is shared between residents, even trace contamination can transmit bloodborne pathogens. The required disinfection protocol, leaving the surface wet with an EPA-approved solution for a full two minutes, exists because a quick wipe with an alcohol pad does not reliably kill what needs to be killed.
Inspectors reviewed infection control practices for five sampled residents and found the problem in one of them, Resident 31's case. The report does not indicate Resident 31 suffered any documented harm as a result. The cited level of harm is minimal harm or potential for actual harm, the lower end of the federal scale. The finding affected few residents, by the report's own categorization.
But the finding also reflects something the numbers don't fully capture: Staff 6 had been doing this long enough, and consistently enough, that she had formed a belief about how the rest of the staff handled it too. That kind of assumption doesn't develop overnight.
The inspection was completed May 22. The report does not say how long Staff 6 had been cleaning the glucometer this way, how many residents had their blood drawn with that device before inspectors arrived, or whether the facility had conducted any internal audits of the practice before the visit.
What it does say is that a nurse wiped a blood-contacting device with the wrong product, put it back in the cart, and assumed that was how things were done. Nobody had told her otherwise.
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 device at the center of the finding was a 2017 Evencare G2 glucometer, used to draw and test blood samples from residents.
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.