Marquis Mill Park
MARQUIS MILL PARK in PORTLAND, OR — inspection on April 24, 2026.
Found 9 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Federal health inspectors cited MARQUIS MILL PARK in PORTLAND, OR for a deficiency under regulatory tag F-F0554 during a standard health inspection conducted on 2026-04-24.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Allow residents to self-administer drugs if determined clinically appropriate.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 9 deficiencies cited during this inspection of MARQUIS MILL PARK.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-06-13.
Federal health inspectors cited MARQUIS MILL PARK in PORTLAND, OR for a deficiency under regulatory tag F-F0578 during a standard health inspection conducted on 2026-04-24.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 9 deficiencies cited during this inspection of MARQUIS MILL PARK.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-06-13.
(injury/decline/room, etc.) that affect the resident.
representative after a change of condition for 1 of 1 resident (#87) reviewed for notifications.
This
admitted to the facility in 11/2024 with diagnoses including surgical treatment after a hip fracture, dementia, and anxiety disorder.A Resident Designation Form from 11/8/24 stated Resident 87 elected to have Witness 2 contacted in case of emergency.A Skilled Nursing Progress Note from Staff 21 (LPN) 12/3/24 revealed Resident 87 had the onset of a new possible infection at the surgical site of her/his left hip.
Staff 23 (Nurse Practitioner) and Staff 22 (RNCM) were notified of this change of condition.
Staff 23 directed Staff 21 to start Resident 87 on cephalexin, (an antibiotic).A 12/3/24 Physician Order directed cephalexin to be started on 12/3/25 to address Resident 87's suspected wound infection.
Review of the 12/2025 MAR revealed Resident 87 started on an antibiotic, cephalexin, on the evening of 12/3/25.A 12/5/24 progress note revealed Staff 22 (RNCM) contacted Resident 87's family regarding the suspected infection and starting an antibiotic.On 4/22/26 at 2:49 PM Witness 2 (Family Member) stated she/he requested to be notified of any change of condition experienced by Resident 87.
Witness 2 stated she/he was not notified on 12/3/24 when Resident 87's had a suspected infection at the surgical site at her/his left hip. On 4/23/26 at 11:04 AM Staff 21 stated she made the Resident Care Manager aware of the suspected infection and was not aware if Resident 87's family was notified of Resident 87's change of condition.On 4/23/26 at 11:51 AM Staff 22 stated family members were contacted when a resident experiences a change of condition.
Staff 22 confirmed Resident 87 was suspected to have a wound infection, and treatment was started to treat the infection on 12/3/24, but Resident 87's emergency contact was not alerted of Resident 87's change of condition until 12/5/24.On 4/23/26 at 12:29 PM Staff 2 (DNS) confirmed she would consider a potential infection a change of condition which required notification to a resident's emergency contact and Resident 87's emergency contact should have been contacted on 12/3/24.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
385214 04/24/2026
Marquis Mill Park 1475 SE 100th Avenue Portland, OR 97216
residents at risk for continued depravation of goods and services.
Findings include:Resident 86
disorder.
The 7/31/25 admission MDS assessed Resident 86 as cognitively intact.
The facility submitted a Facility Reported Incident (FRI) on 8/16/25 indicating Resident 86 received fraud alerts from her/his financial institutions and discovered two credit cards and one debit card missing. Resident 86 reported Staff 10 (Former Maintenance Assistant) had entered her/his room multiple times over the prior weeks without clear request, reportedly to check equipment.
Interview with the resident's family and record review revealed fraudulent charges between 8/4/25 and 8/16/25 totaling over $1300, including a charge at a gas station in the same town where Staff 10 resided as well as miscellaneous online purchases.
The employee was placed on immediate administrative leave.The facility's investigation revealed video surveillance footage confirmed Staff 10 utilized the resident's credit and debit cards at a local gas station and for miscellaneous online purchases.
The facility also obtained footage of Staff 10 entering Resident 86's room on multiple occasions without a documented work order or request for maintenance services.
Law enforcement was notified, and a police report was filed.
The facility reimbursed Resident 86 for the fraudulent charges. A facility-wide audit was conducted to determine if other residents experienced missing property, no additional concerns were identified.Resident 86 experienced financial loss exceeding $1300 and emotional distress related to the unauthorized use of her/his personal financial accounts, which resulted in her/him electing to move rooms due to concerns for personal safety and security. On 4/21/26 at 10:24 AM Witness 1 (Family Member) confirmed the cards were kept in Resident 86's room and no permission had been given for anyone to use them.
Witness 1 stated Resident 86 elected to move from her/his private room to another private room following the incident for an increased sense of security. On 4/23/26 at 9:45 AM Staff 2 (DNS) confirmed she was aware of the incident which occurred on 8/16/25 regarding Resident 86 and misappropriation of funds had occurred.
Staff 2 stated it was her expectation residents were protected from misappropriation and staff did not take or utilize resident property. On 4/23/26 at 9:50 AM Staff 9 (Former Administrator) confirmed misappropriation of funds occurred on 8/16/25 regarding Resident 86 and stated Staff 10 was immediately removed from the schedule, reported to law enforcement, and subsequently terminated.
Staff 9 stated she expected staff to immediately report any misappropriation concerns and always protect resident property.
Staff 9 further stated the facility offered lockboxes to residents for personal belongings, and residents retain the key for added security. On 4/23/26 at 10:26 AM Staff 1 (Administrator) confirmed the 8/16/25 incident occurred and Resident 86 had funds stolen and used by Staff 10.
Staff 1 stated immediate actions was taken to address the misappropriation of funds.
Staff 1 stated she expected resident property was protected and staff immediately report allegations of misappropriation. On 4/24/26 at 8:57 AM Staff 10 stated he did not provide a statement regarding the allegation of resident stolen property.
Staff 10 confirmed he was placed on administrative leave and was subsequently terminated.
The incident met the criteria for past noncompliance as follows:The deficient practice was identified as Past Noncompliance based on the following:-On 8/16/25, the deficient practice was identified by the facility, and the facility completed a root cause analysis of the incident and determined misappropriation of funds occurred.
The plan of correction included:1.
Staff 10 was placed on leave pending the investigation and was subsequently terminated. 2.
Staff were provided with in-services training including reeducation regarding abuse and misappropriation of funds and all required training was completed by 9/10/25.3.
Audits were conducted to ensure ongoing compliance and staff adherence to appropriate practices regarding misappropriation of funds. 4.
Ongoing Quality Assurance oversight.
Federal health inspectors cited MARQUIS MILL PARK in PORTLAND, OR for a deficiency under regulatory tag F-F0628 during a standard health inspection conducted on 2026-04-24.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 9 deficiencies cited during this inspection of MARQUIS MILL PARK.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-06-13.
Federal health inspectors cited MARQUIS MILL PARK in PORTLAND, OR for a deficiency under regulatory tag F-F0695 during a standard health inspection conducted on 2026-04-24.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide safe and appropriate respiratory care for a resident when needed.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 9 deficiencies cited during this inspection of MARQUIS MILL PARK.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-06-13.
Federal health inspectors cited MARQUIS MILL PARK in PORTLAND, OR for a deficiency under regulatory tag F-F0760 during a standard health inspection conducted on 2026-04-24.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure that residents are free from significant medication errors.
Scope/Severity Level G: isolated, actual harm that is not immediate jeopardy.
Actual harm to residents was documented as a result of this deficiency.
This was one of 9 deficiencies cited during this inspection of MARQUIS MILL PARK.
Correction Status: Past Non-Compliance.
The facility reported correction as of 2026-04-15.
Federal health inspectors cited MARQUIS MILL PARK in PORTLAND, OR for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2026-04-24.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 9 deficiencies cited during this inspection of MARQUIS MILL PARK.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-06-13.
Federal health inspectors cited MARQUIS MILL PARK in PORTLAND, OR for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2026-04-24.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Provide and implement an infection prevention and control program.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 9 deficiencies cited during this inspection of MARQUIS MILL PARK.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-06-13.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.