Average — CMS composite of the measures below.
The next survey window likely opens around April 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 Tualatin Post Acute Rehab during CMS and state inspections, most recent first.
A shared glucometer was not properly disinfected between resident CBG checks. A nurse wiped the device with an alcohol pad instead of an EPA-approved disinfectant wipe, despite the facility policy and manufacturer instructions requiring approved disinfectant use after each resident. The resident involved had Hepatitis B and received routine CBG monitoring, and multiple staff members used the same glucometer.
Unsanitary food storage was observed in a communal freezer when an opened ice cream bar was left uncovered and unlabeled, a small ice cream container was not labeled or dated, and dried and spilled substances were present on the freezer walls and shelf. The Administrator and Dietary Manager observed the findings with the surveyor and stated the items needed to be discarded and the spills cleaned.
Failure to Provide Assistance With Personal Hygiene: A resident with Parkinson's disease and hand tremors required supervision, cueing, and assistance with shaving, but staff did not consistently offer or provide the needed help after showers. Observations showed the resident's beard was overgrown, and staff reported they either did not notice the need or did not have time to assist.
A facility failed to follow physician orders for two residents. One resident with kidney failure and diabetes missed ordered Aspirin, Vitamin B12, and morning CBG checks on dialysis days because the resident was out of the facility. Another resident with deafness, renal/ureter obstruction, and a history of vomiting had daily nausea and vomiting that were not consistently managed; PRN ondansetron was delayed, sometimes not offered, and staff acknowledged the medication was not consistently administered.
A resident with a stroke, severe cognitive impairment, and ROM impairment was ordered to wear a contracture boot on the right foot for two hours on and two hours off, but observations showed the boot sitting beside the bed with no observed use. A family member reported staff were not placing the boot regularly, and the Rehab Director and DNS acknowledged the resident was not regularly assisted with the prescribed boot.
A medication and treatment cart was found unlocked and unattended on two occasions by the same RN, contrary to the facility's policy. The RN acknowledged the oversight, and the DNS confirmed the requirement for carts to be locked when not in use.
A resident with a right femur fracture discovered a fraudulent check for $2,000 written to an agency CNA, who was assigned to them on specific dates. The check was forged and cashed without the resident's consent. The facility reported the incident to law enforcement and the Oregon Board of Nursing, but the CNA was unreachable.
A facility failed to thoroughly investigate an alleged misappropriation of property involving a resident. A fraudulent check was written from the resident's checkbook and cashed by a former agency CNA. The investigation did not include interviews with the resident or the accused, nor a review of the resident's personal inventory. This oversight was acknowledged by the facility's administrator, highlighting a risk for misuse of personal funds.
A resident's representative was not informed of a fall incident due to a lack of signed documentation, despite verbal confirmation of their role. The LPN did not notify the family, believing the resident was their own representative. The RNCM and Administrator later acknowledged the oversight, confirming the representative should have been informed.
A resident with BPH and depression required a two-person mechanical lift for transfers. After a fall from a wheelchair due to dizziness, the resident was not monitored for latent injuries as per facility protocol. Additionally, during a transfer, the resident's head was struck by a mechanical lift due to a CNA's hurried actions, and the incident was not reported to a nurse for assessment. Staff interviews confirmed these lapses in following safety procedures.
A resident with a urinary catheter experienced inadequate catheter care, leading to infection risk. Despite a care plan requiring daily cleaning, staff inconsistencies were noted, with some CNAs not performing necessary care. The resident showed symptoms of a UTI and was sent to the hospital, where issues like catheter leakage and sores were observed. Staff interviews revealed a lack of consistent care due to unfamiliarity and reliance on agency staff.
Improper Disinfection of Shared Glucometer
Penalty
Summary
The facility failed to properly disinfect a shared glucometer between resident uses during CBG checks. The facility’s glucometer disinfection policy directed staff to disinfect after each individual patient use with EPA disinfectant wipes, and the glucometer manufacturer manual stated that common use glucometers were to be wiped with an approved disinfectant wipe and left wet for two minutes to ensure disinfection. During observation, Staff 6 obtained a CBG for a resident and then returned to the medication cart, wiped the glucometer with an alcohol pad wipe, and placed it back inside the cart. Staff 6 stated she always cleaned glucometers with an alcohol pad wipe after use and believed other staff did the same. Resident 1 was admitted with diagnoses including Hepatitis B and received CBG monitoring before meals and at bedtime from multiple staff members, including Staff 6. The facility census indicated 13 residents received daily CBG monitoring, including Resident 1. Staff 2, the DNS, stated staff were expected to use EPA-approved disinfecting wipes to clean glucometers after each resident use and acknowledged that alcohol pad wipes were not sufficient. The report identified the failure to properly disinfect the common use glucometer as an Immediate Jeopardy situation.
Unsanitary Food Storage in Communal Freezer
Penalty
Summary
The facility failed to store food in a sanitary manner in the communal freezer in the dining room kitchenette. During the initial tour, surveyors observed an opened ice cream bar that was uncovered and not labeled or dated, a small ice cream container covered with a plastic lid but also not labeled or dated, dried brown substance smudged on the sides of the freezer wall, and spilled substance stuck on the bottom of the freezer shelf. Staff 1, the Administrator, and Staff 17, the Dietary Manager, observed the items with the surveyor and indicated that the items in the freezer needed to be thrown away and the spilled substances needed to be cleaned.
Failure to Provide Assistance With Personal Hygiene
Penalty
Summary
The facility failed to provide personal hygiene for one resident who was unable to complete shaving without assistance. The resident was admitted in 10/2022 with Parkinson's disease, had a 4/27/26 quarterly MDS showing a BIMS score of 15, and the care plan required supervision with cueing and assistance during shaving. The facility's 2022 Standards of Care stated staff were required to shave residents as needed. Record review showed staff documented providing assistance with personal hygiene on 5/18/26 and 5/21/26, but during random observations from 5/18/26 through 5/21/26 the resident's beard was unkempt and overgrown with gray and brown hairs. The resident stated on 5/20/26 and again on 5/21/26 that staff did not offer to assist with shaving after showering and that the resident had asked multiple times for help but staff were not available. The resident also stated a right-hand tremor made shaving challenging and that the resident did not feel good because staff did not have time to help. Staff 8 stated the resident had occasional hand tremors and required staff to set up and help with shaving, but she did not offer because she did not notice the overgrown facial hair. Staff 9 stated the resident required minimal assistance with personal hygiene including shaving, but she did not have time to shave the resident and did not tell other staff. The RNCM stated she expected staff to offer to shave residents after showers and was unaware that personal hygiene was not being completed after showers.
Failure to Follow Ordered Medications, Dialysis-Related Care, and PRN Nausea Treatment
Penalty
Summary
The facility failed to follow physician orders for Resident 18, who was admitted with kidney failure and diabetes. Current orders included daily Aspirin, daily Vitamin B12, and blood glucose checks in the morning and at bedtime, but the 5/2026 MAR showed the resident did not receive Aspirin, Vitamin B12, or morning CBG checks on multiple days. Staff 6 stated the resident went to dialysis early in the morning on Tuesday, Thursday, and Saturday, and on those days the resident did not receive morning medications or CBG checks because the resident was out of the facility. Staff 3 acknowledged the resident did not receive medication and treatment as ordered on mornings the resident was sent to dialysis. The facility also did not consistently address Resident 31’s nausea and vomiting. Resident 31 was readmitted with deafness and hydronephrosis with renal and ureter obstruction, and the MDS indicated a BIMS score of zero and a history of vomiting. A family member stated the resident had daily nausea and vomiting, was a poor historian, and was uncomfortable every day. The resident was observed vomiting, coughing, gagging, grimacing, and pointing to the belly and throat, yet PRN ondansetron was not consistently given; one dose was administered seven hours after a vomiting episode and was documented as ineffective, and no record was found showing PRN medication was offered when the resident returned to the room after breakfast symptoms. Staff 10, Staff 11, Staff 12, Staff 6, and Staff 3 all acknowledged the resident’s nausea and vomiting were not consistently managed and that PRN ondansetron was not consistently administered.
Failure to Assist Resident With Prescribed Contracture Boot
Penalty
Summary
The facility failed to ensure staff assisted a resident with use of a prescribed contracture boot to maintain range of motion and mobility. Resident 5 was admitted in 2/2026 with diagnoses including a stroke. The 2/15/26 admission MDS indicated severe cognitive impairment and range of motion impairment in a lower extremity. The revised 4/27/26 care plan stated the resident required a contracture boot to be placed on the right foot for two hours on and two hours off. Random observations from 5/18/26 through 5/21/26 showed the contracture boot sitting on the chair next to the resident's bed, with no observed instances of the boot being on the resident's foot. A family member stated staff failed to place the boot regularly and was concerned the resident would develop a contracture. A CNA stated the resident required a splint on the right arm and could not provide information about the contracture boot. Another CNA stated the resident was unable to move the right upper and lower extremities due to a severe stroke and could not speak to interventions in place to prevent ROM decline. The Rehab Director stated the resident benefited from the boot to prevent contracture and to prevent right foot drop or foot inversion. The DNS acknowledged staff did not regularly assist the resident to use the contracture boot.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure the security of medications and biologicals, as observed during a survey. On two separate occasions, a medication and treatment cart located adjacent to the nursing station on the A-hall was found unlocked and unattended. The first incident occurred when Staff 5, an RN, left the cart unsecured while out of sight, and it was subsequently locked by Staff 6, another RN, who noticed the oversight. The second incident involved the same staff member, Staff 5, who again left the cart unlocked and unattended, only to secure it upon returning to the cart. During interviews, Staff 5 acknowledged leaving the cart unlocked and unattended, which was against the facility's policy requiring medication carts to be locked when not in use or out of the nurse's view. Staff 2, the Director of Nursing Services (DNS), was informed of these incidents and confirmed that the cart should have been locked to prevent unauthorized access to medications. These lapses in securing the medication cart placed residents at risk for unauthorized access to medications.
Misappropriation of Resident Funds by Agency CNA
Penalty
Summary
The facility failed to prevent the misappropriation of financial resources by a former agency CNA, identified as Staff 7, involving a resident who was cognitively intact. The resident, admitted with a right femur fracture, discovered a fraudulent check written from their checkbook to Staff 7 for $2,000. The check was forged and cashed while the resident was at the facility. The resident kept their checkbook in the nightstand drawer and did not authorize any staff to access it or sign checks on their behalf. The facility's investigation revealed that Staff 7 was assigned to the resident on specific dates and was asked not to return to work due to declining to care for residents. The fraudulent activity was reported to law enforcement and the Oregon Board of Nursing. Despite attempts to contact Staff 7, they were unreachable. The facility acknowledged the misappropriation of funds but noted no other reports of similar incidents.
Incomplete Investigation of Misappropriation of Resident Property
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged misappropriation of property involving a resident. The incident involved a fraudulent check written from the resident's checkbook, which was cashed by a former agency CNA. The facility's investigation was incomplete as it did not include interviews with the resident or the accused employee, nor did it review the resident's personal inventory record. Additionally, staff members who had contact with the resident were not interviewed, which was acknowledged by the facility's administrator. The resident, who was cognitively intact, was admitted with a right femur fracture and discharged shortly before the incident was reported. The facility's policy required specific steps to be taken during an investigation of misappropriation, including interviews and inventory checks, which were not followed. The failure to adhere to these procedures placed residents at risk for misuse of personal funds, as the investigation was not comprehensive enough to address all aspects of the alleged abuse.
Failure to Notify Resident's Representative of Fall Incident
Penalty
Summary
The facility failed to notify a resident's representative of a fall incident involving a resident who was admitted with diagnoses including benign prostatic hyperplasia and depression. The resident's admission record indicated that a family member, identified as Witness 15, was the resident's representative and emergency contact. However, there was no documentation in the clinical record confirming that Witness 15 had signed paperwork as the resident's representative. Witness 15 reported not being informed by the facility about the resident's fall. Staff interviews revealed that the LPN did not contact the family because the resident was considered their own representative, while the RNCM acknowledged that Witness 15 should have been notified if they were the resident's representative. The Admissions Director confirmed that Witness 15 was verbally appointed as the resident's representative during the admission process, although no paperwork was signed. The Administrator also acknowledged that Witness 15 should have been notified about the fall.
Failure to Monitor Resident After Fall and Safe Transfer
Penalty
Summary
The facility failed to ensure that a resident received appropriate care plan interventions for safe transfer and monitoring after a fall. The resident, admitted with diagnoses including benign prostatic hyperplasia and depression, required a two-person mechanical lift for transfers. On one occasion, the resident was found on the floor after falling from a wheelchair due to dizziness. Although the resident was assessed for immediate injuries, there was no documentation of monitoring for latent injuries following the fall, as expected by the facility's protocol. Staff interviews confirmed that the resident was not placed on alert charting for 72 hours post-fall, which was a standard procedure to monitor for latent injuries. Additionally, an incident occurred during a transfer using a mechanical lift, where the resident's head was struck due to the CNA operating the lift in a hurried manner. Despite the incident, the CNAs involved did not report it to a nurse, and the resident was not assessed for potential injuries. Staff interviews revealed that the incident was not communicated to the charge nurse, which was against the facility's expectations for reporting potential injuries. The administrator acknowledged these findings, indicating a lapse in following the facility's procedures for ensuring resident safety during transfers and post-fall monitoring.
Inadequate Catheter Care Leads to Infection Risk
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident, leading to an increased risk of infection. The resident, admitted with diagnoses including benign prostatic hyperplasia and hematuria, had a urinary catheter in place. The care plan required daily catheter care with soap and water and monitoring for signs of infection. However, staff interviews revealed inconsistencies in providing catheter care, with some staff admitting to not performing necessary cleaning or peri care. The resident experienced symptoms indicative of a urinary tract infection, including elevated temperatures and hematuria. A public complaint and family member testimony indicated that the resident arrived at the hospital with a leaking catheter, pain, dark cloudy urine, and sores on the genitalia. Hospital staff reported blood and discharge from the genitalia and erosion at the catheter entry point, suggesting improper catheter positioning. Staff interviews highlighted a lack of consistent catheter care, with some CNAs and LPNs acknowledging inadequate care due to unfamiliarity with residents and reliance on agency staff. The facility's administration and nursing staff recognized the deficiency, noting that catheter care was expected to be performed daily, and any issues should have been reported to the charge nurse or physician.
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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 Tualatin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avamere Rehabilitation Of King City | 2.2 mi | ★★★★★ | 13 | 0 |
| Tigard Rehabilitation And Care | 3.1 mi | ★★★★★ | 19 | 2 |
| Pearl At Kruse Way, The | 3.9 mi | ★★★★★ | 3 | 0 |
| Marquis Wilsonville Post Acute Rehab | 5.5 mi | ★★★★★ | 3 | 0 |
| Rose Linn Care Center | 5.6 mi | ★★★★★ | 12 | 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.