Above average — CMS composite of the measures below.
The next survey window likely opens around January 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 Autumn Hills Memory Care during CMS and state inspections, most recent first.
Functional call lights were not available for three residents with dementia-related diagnoses and other care needs. Two residents had care plans or assessments addressing call light use, but all three were observed with their call lights unplugged and no alternate way to call for assistance. Staff could not explain why the call lights were not functional, and a maintenance staff member stated one was removed during room painting and another during battery replacement and not replaced.
Failure to complete required AIMS monitoring for a resident receiving quetiapine. A resident with vascular dementia with agitation and depression was prescribed quetiapine 75 mg BID, but the record showed no AIMS assessment completed on admission. The RNCM/DNS/IP believed AIMS was not needed until 6 months after admission, while the Regional RN Consultant confirmed the resident required AIMS on admission and every 6 months while on antipsychotic medication.
A resident with severe cognitive impairment and care plan directions for dressing and shaving assistance was observed wearing the same clothes for multiple days, with an overgrown beard and mustache. The resident stated he/she had not shaved and was unsure when clothes were last changed. Staff reported the resident was cooperative and redirectable, but also said daily personal hygiene supplies needed to be set up and that this was not completed because staff were busy with other residents.
Failure to Provide Written Bed Hold Notification: A resident with diabetes and heart disease was transferred to the hospital multiple times, but the record showed no written bed hold notice, including reserved bed hold payment information, was provided to the resident or representative at the time of transfer. An LPN stated the charge nurse was to open an assessment and provide the notice, and the RNCM/DNS/IP confirmed it was not provided.
Two residents with moderate cognitive impairment were involved in a physical altercation after a dispute over the room light, resulting in one resident being pushed onto the bed and expressing fear and pain. Staff and administrative interviews confirmed the incident met the definition of abuse.
The facility was found deficient in medication storage practices. A medication cart was left unlocked and unattended, and an expired bottle of Lorazepam was found in the medication refrigerator. These issues were confirmed by staff and reported to the Administrator, with no further information provided.
The facility did not implement Enhanced Barrier Precautions for residents with catheters, as required by their policy. Observations revealed no signage or PPE readily available, and staff were unaware of the precautions. This lack of implementation and communication among staff led to a deficiency in infection control practices.
A facility failed to inform a resident with vascular dementia about the risks and benefits of Duloxetine, an antidepressant prescribed to them. The deficiency was identified through interviews and record reviews, which revealed that the medical records did not contain documentation of this information being shared with the resident. An LPN confirmed that the necessary information was not provided.
A resident with vascular dementia and malnutrition experienced significant weight loss, which the facility failed to assess and address. Despite a care plan goal to maintain or increase weight, the resident's weight decreased over several months without additional interventions. Staff interviews revealed failures in identifying the weight loss on the MDS, notifying relevant parties, and implementing necessary interventions.
A facility failed to offer a pneumococcal vaccination to a resident admitted with chronic pain. The resident's immunization records lacked documentation of assessment, offer, or declination of the vaccination. A Regional RN confirmed the absence of such documentation in the medical record.
A resident experienced prolonged pain and a delayed diagnosis of a hip fracture after multiple falls. Despite repeated complaints of pain, the facility failed to ensure timely x-rays and appropriate follow-up care. The hip fracture was diagnosed 31 days after the initial fall, requiring hospitalization and surgery.
The facility failed to protect residents from physical abuse, as evidenced by an incident where a resident with a history of aggression caused injuries to another resident with severe cognitive impairment. Staff supervision was inadequate at the time of the incident.
Functional Call Lights Not Available for Three Residents
Penalty
Summary
Functional call lights were not available for 3 of 3 sampled residents reviewed for accommodation of needs. The facility’s policy required staff to assess residents for call light use at admission and after a significant change, and to document call light safety risks in the resident record. Resident 20, admitted in 2/2024 with unspecified dementia, had a revised care plan dated 8/30/25 indicating use of a pressure sensitive call light pad. Resident 21, admitted in 8/2025 with unspecified dementia and repeated falls, had a revised care plan dated 2/14/26 that did not include information related to call light use. Resident 26, admitted in 6/2019 with Alzheimer’s disease, had a Call Light Safety Assessment dated 8/18/23 stating the resident was aware and able to use a call light. On 2/23/26, 2/24/26, and 2/25/26, Residents 20, 21, and 26 were observed with their call lights unplugged from the call light box in their rooms, and no alternative means to call for assistance was available. Staff 9 stated residents were supposed to have functional call lights but did not know why these residents did not. Staff 7 stated every resident was supposed to have a functional call light and did not know why these residents did not have one in place. Staff 8 stated he had removed Resident 26’s call light while painting the room and forgot to replace it, and stated Resident 20’s call light was removed when he replaced batteries in the call light box. Staff 8 also could not identify why Resident 21 did not have a functional call light. Staff 2 acknowledged that functional call lights were required for all residents.
Failure to Complete Required AIMS Monitoring for Antipsychotic Use
Penalty
Summary
The facility failed to provide adequate monitoring of antipsychotic medication use for one resident who was admitted with diagnoses including vascular dementia with agitation and depression. A physician order dated 1/12/26 showed the resident was prescribed quetiapine 75 mg twice daily. Review of the medical record found no indication that an Abnormal Involuntary Movement Scale (AIMS) assessment had been completed to identify symptoms or side effects of psychoactive medication use. On 2/26/26, the RNCM/DNS/IP stated the resident was already taking an antipsychotic medication on admission and believed an AIMS was not required until six months after admission. Later that day, the Regional RN Consultant stated the resident required an AIMS assessment upon admission and every six months while receiving antipsychotic medication, and confirmed that no AIMS had been completed upon admission.
Failure to Provide Daily Dressing and Personal Hygiene Assistance
Penalty
Summary
The facility failed to ensure assistance was provided with dressing and personal hygiene for one resident who was reviewed for ADLs. The resident was admitted with diagnoses including delusional disorders, had a care plan indicating the resident required supervision and assistance with dressing, and the quarterly MDS showed a BIMS score of 6, indicating severe cognitive impairment. The care plan also directed staff to ensure clothing and footwear were clean, provide assistance with dressing after the resident attempted each step, and offer clothing choices. The Kardex indicated the resident required constant supervision with cueing and minimal physical assistance during shaving. From 2/24/26 through 2/26/26, the resident was observed wearing the same blue sweater, sweatpants, and socks, and the resident's beard and mustache were long and overgrown. The resident acknowledged not having shaved and stated staff had allowed shaving, and later stated being unsure when clothes were last changed or the beard last shaved. Staff 9 stated the resident was independent and cooperative but needed staff to set up personal hygiene supplies daily and that she was unable to shower the resident or set up supplies because she was busy with other residents. Staff 7 stated the resident was redirectable, cooperative, did not refuse care, and was able to complete daily personal hygiene independently, while also stating staff were expected to set up personal hygiene supplies daily. Staff 2 stated she monitored the electronic record for completion of personal hygiene tasks and followed up when documentation was incomplete.
Failure to Provide Written Bed Hold Notification
Penalty
Summary
The facility failed to provide written bed hold notification, including reserved bed hold payment information, to a resident or the resident’s representative at the time of transfer to the hospital. Resident 5 was admitted to the facility in 4/2024 with diagnoses including diabetes and heart disease and was transferred to the hospital on 11/19/25, 11/29/25, 12/2/25, 12/21/25, and 2/10/26. Review of the clinical record found no evidence that written notice of the facility’s bed hold policy was provided on any of those transfers. Staff 10 stated that upon transfer to the hospital, the charge nurse was to open an assessment in the resident’s medical record and provide a bed hold notification, and Staff 2 confirmed that a written bed hold notification was not provided to Resident 5 or the resident’s representative at the time of transfer on the specified dates.
Resident-to-Resident Physical Abuse Following Roommate Dispute
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease and moderate cognitive impairment was physically abused by a roommate with dementia, also exhibiting moderate cognitive impairment. The incident took place in a shared room when one resident turned on the overhead light, waking the other, who became angry, used profanity, and pushed the first resident back onto the bed. The resident who was pushed reported feeling scared and later complained of shoulder pain. Staff interviews confirmed that the incident involved a physical altercation following a dispute over the room light, and both residents had a history of issues related to sharing the room. The event was witnessed and reported by staff, with both residents interviewed after the incident. The resident who was pushed described feeling abused and afraid at the time, while the other resident admitted to pushing due to frustration over the light being turned on. Staff and administrative personnel acknowledged the incident as meeting the definition of abuse, and documentation indicated that the affected resident felt unsafe immediately following the event.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure the secure storage of medications and the removal of expired medications, as observed during a survey. An intermediate care medication cart was found unlocked and unattended outside a resident's room, which was confirmed by a Certified Medication Aide (CMA). Additionally, a multidose bottle of Lorazepam, a controlled antianxiety medication, was discovered in the locked medication refrigerator with an expired date. This was confirmed by a Licensed Practical Nurse (LPN). The facility's Storage of Medication Policy mandates that all drugs and biologicals be stored safely, securely, and in an orderly manner, which was not adhered to in these instances. The findings were communicated to the facility's Administrator, but no additional information was provided in response to these observations.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions for residents with catheters, as required by their own policy. The policy indicated that Enhanced Barrier Precautions should be used for residents with catheters and complex wounds. However, during an observation, it was noted that there was no signage indicating Enhanced Barrier Precautions for residents with catheters, specifically Residents 2, 8, and 14. Staff 8, a CNA, was unaware of any residents on precautions, and Staff 2, the DNS, confirmed that the facility had not implemented the necessary precautions. Staff 2 explained that the facility was waiting for blue sticker dots to indicate Enhanced Barrier Precautions, and that PPE was stored in the spa rather than in the hallways. However, upon checking, it was found that hospital gowns were not stored in the spa as expected. Staff 7, another CNA, was also unaware of any precautions being followed for residents with indwelling catheters. This lack of implementation and communication among staff led to the deficiency in infection control practices.
Failure to Inform Resident of Psychotropic Medication Risks and Benefits
Penalty
Summary
The facility failed to inform residents of the risks and benefits associated with the use of psychotropic medications, specifically for one resident who was part of a sample of five reviewed for medication use. This deficiency was identified through interviews and record reviews. The resident in question was admitted to the facility in August 2024 with a diagnosis of vascular dementia. Physician orders dated October 22, 2024, indicated that the resident was to receive Duloxetine, an antidepressant, daily. However, the medical records lacked documentation that the risks and benefits of Duloxetine were discussed with the resident. On October 24, 2024, a Licensed Practical Nurse (LPN) acknowledged that this information had not been provided to the resident.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to adequately assess and address significant weight loss in a resident diagnosed with vascular dementia and malnutrition. The resident was admitted in May 2023 with a care plan goal to maintain or increase weight above 167 pounds. Despite a dietitian's assessment in May 2024 indicating the resident weighed 157.4 pounds and would benefit from weight gain, subsequent progress notes in July and August 2024 showed stable weight without additional interventions. By September 2024, the resident's weight had decreased to 156.4 pounds, reflecting a 10-pound loss over the previous month and a seven-pound loss over six months, yet no further interventions were implemented. The facility's records from July to October 2024 lacked additional assessments of the resident's weight loss. The October 2024 Quarterly MDS inaccurately indicated no weight loss, despite the resident weighing 158.6 pounds and experiencing significant weight loss over 180 days. Staff interviews revealed that the resident care manager failed to identify the weight loss on the MDS and did not notify the provider, family, or dietitian, nor was the resident added to the Nutrition at Risk list. The registered dietitian confirmed she was not informed of the weight loss and had not assessed the resident since May 2024. The regional RN acknowledged that required interventions, such as dietitian referral and nutrition assessment, were not in place for the resident.
Failure to Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to offer pneumococcal immunizations to a resident, which was identified during an interview and record review. The resident was admitted in February 2024 with a diagnosis of chronic pain. Upon review, it was found that the resident's immunization records did not indicate whether they were assessed for, offered, or declined a pneumococcal vaccination after admission. On October 24, 2024, a Regional RN confirmed that there was no documentation in the medical record showing that the facility offered a pneumococcal vaccination to the resident.
Failure to Address Resident's Pain and Delayed Diagnosis of Hip Fracture
Penalty
Summary
The facility failed to act upon complaints of hip pain and rule out significant injury after multiple falls for a resident reviewed for falls. The resident experienced prolonged pain over a period of four weeks and a delay in diagnosis of a hip fracture requiring hospitalization and surgery. The hip fracture was not diagnosed until 31 days after the resident's fall. The resident was admitted to the facility with diagnoses including stroke and dementia and was identified as a fall risk due to impaired mobility, gait unsteadiness, and decreased safety awareness. The resident experienced three falls on 7/4, 7/8, and 7/9, with complaints of pain following each fall. Despite these complaints, the facility failed to ensure timely x-rays and appropriate follow-up care. An x-ray ordered after the second fall was canceled by the service provider and not rescheduled. Throughout July and early August, the resident repeatedly complained of pain, which was documented in progress notes. The resident was administered PRN Norco for pain relief multiple times, but the pain persisted. It was not until 8/4 that a left hip x-ray was ordered, revealing an acute superiorly displaced subcapital fracture of the left femoral neck. The resident was then sent to the emergency department for evaluation and treatment.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to ensure residents were free from physical abuse, as evidenced by an incident involving two residents with dementia. Resident 1, who had a history of physical and verbal aggression, was observed standing over Resident 2 and holding Resident 2's wrist. Resident 2, who had severe cognitive impairment, was found lying on a couch with scratches on her face. Staff 6, a CNA, confirmed that she was in the living room with the residents but had left briefly to wash her hands. Upon hearing Resident 2 yelling, she returned to find Resident 1's hands on Resident 2's face, resulting in two skin tears on Resident 2's face. Staff 7, another CNA, confirmed that Resident 1 required close supervision due to aggressive behaviors but was on break when the incident occurred. Both residents were observed on subsequent days and had no recall of the incident. The facility's report indicated that the incident was reported to the charge nurse immediately after it occurred. The facility's administrator and DNS were notified of the investigative findings but provided no further information. The failure to provide adequate supervision and protection for Resident 2 from Resident 1's aggressive behavior constitutes a deficiency in ensuring residents are free from physical abuse.
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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 Portland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Robison Jewish Health Center | 0.1 mi | ★★★★★ | 23 | 0 |
| Marquis Vermont Hills | 0.4 mi | ★★★★★ | 2 | 0 |
| West Hills Health & Rehabilitation | 1.3 mi | ★★★★★ | 0 | 0 |
| Avamere Crestview Of Portland | 1.6 mi | ★★★★★ | 11 | 0 |
| Beaverton Post Acute Care Of Cascadia | 3 mi | ★★★★★ | 1 | 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.