MARQUIS AUTUMN HILLS MEMORY CARE

6630 SW BEAVERTON-HILLSDALE HWY, PORTLAND, OR 97225 (503) 292-7874
For profit - Limited Liability company 39 Beds Independent Data: November 2025
Trust Grade
48/100
#59 of 127 in OR
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Last Inspection: October 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Marquis Autumn Hills Memory Care has a Trust Grade of D, indicating below-average performance with some concerns about care quality. In Oregon, the facility ranks #59 out of 127, placing it in the top half of nursing homes in the state, and #6 out of 9 in Washington County, meaning only two local options are better. The facility is improving, having reduced issues from 7 in 2024 to just 1 in 2025. Staffing is a relative strength with a rating of 4 out of 5 stars and a low turnover rate of 27%, which is significantly below the state average. Notably, there have been no fines recorded, suggesting compliance with regulations. However, there are serious incidents to consider. One resident experienced prolonged pain due to a delayed diagnosis of a hip fracture that went unrecognized for 31 days after a fall. Additionally, there were concerns about medication safety, as one medication cart was found unlocked, creating a risk of misuse, and infection control protocols were not properly implemented for residents with special needs. While there are strengths in staffing and compliance, these specific incidents raise valid concerns that families should weigh when considering this facility for their loved ones.

Trust Score
D
48/100
In Oregon
#59/127
Top 46%
Safety Record
High Risk
Review needed
Inspections
Getting Better
7 → 1 violations
Staff Stability
✓ Good
27% annual turnover. Excellent stability, 21 points below Oregon's 48% average. Staff who stay learn residents' needs.
Penalties
✓ Good
No fines on record. Clean compliance history, better than most Oregon facilities.
Skilled Nurses
○ Average
Each resident gets 34 minutes of Registered Nurse (RN) attention daily — about average for Oregon. RNs are the most trained staff who monitor for health changes.
Violations
⚠ Watch
13 deficiencies on record. Higher than average. Multiple issues found across inspections.
★★★☆☆
3.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★★
5.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 7 issues
2025: 1 issues

The Good

  • 4-Star Staffing Rating · Above-average nurse staffing levels
  • 5-Star Quality Measures · Strong clinical quality outcomes
  • Low Staff Turnover (27%) · Staff stability means consistent care
  • Full Sprinkler Coverage · Fire safety systems throughout facility
  • No fines on record
  • Staff turnover is low (27%)

    21 points below Oregon average of 48%

Facility shows strength in staffing levels, quality measures, staff retention, fire safety.

The Bad

3-Star Overall Rating

Near Oregon average (3.0)

Meets federal standards, typical of most facilities

The Ugly 13 deficiencies on record

1 actual harm
May 2025 1 deficiency
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

Based on interview and record review it was determined the facility failed to honor the resident's right to be free from physical abuse from other residents for 1 of 6 sampled residents (#2) reviewed ...

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Based on interview and record review it was determined the facility failed to honor the resident's right to be free from physical abuse from other residents for 1 of 6 sampled residents (#2) reviewed for abuse. This placed residents at risk for physical abuse. Findings include: Resident 2 admitted to the facility in 3/2025 with diagnoses including Alzheimer's disease. Resident 2's 3/17/25 admission MDS revealed she/he had a BIMS of 9, which indicated moderate cognitive impairment.Resident 3 admitted to the facility in 8/2023 with diagnoses including dementia.Resident 3's 2/24/25 Quarterly MDS revealed she/he had a BIMS of 12, which indicated moderate cognitive impairment.An 4/19/25 facility Investigation Summary and Conclusion revealed on the morning of 4/19/25 Resident 2 and Resident 3 were in their shared room asleep when Resident 2 woke up and turned on the overhead light. Resident 3 woke up and became angry, swore at Resident 2, and pushed her/him back onto her/his bed. Resident 3 then went to the common television room to complain about the overhead light being on. The facility moved the residents to different rooms. Neither resident was injured during the incident.Resident 2's 4/19/25 Resident to Resident Event Assessment revealed Resident 2 was interviewed after the incident and stated Resident 3 cursed at her/him when the bedroom light was turned on. Resident 2 stated Resident 3 then shoved her/him hard onto the bed and attacked her/him because she/he turned on the light. Resident 2 stated the incident scared her/him and she/he complained of left shoulder pain later in the day.Resident 3's 4/19/25 Resident to Resident Event Assessment revealed Resident 3 was interviewed after the incident and stated Resident 2 stood over her/his bed yelling and Resident 3 then pushed Resident 2 onto her/his bed. On 5/15/25 at 7:51 AM Staff 6 (CNA) stated she worked on 4/19/25 and recalled the incident between Resident 2 and Resident 3. Staff 6 stated she found Resident 3 screaming about pushing Resident 2 because she/he turned the light on. Resident 2 was very scared and wanted to be out of the shared room. The two residents were then separated. On 5/15/25 at 1:25 PM Resident 3 stated she/he and Resident 2 had many issues because they shared a room and Resident 2 turned the light on every night. Resident 3 stated on 4/19/25 Resident 2 woke her/him up when she/he turned the light on. Resident 3 stated the two residents then went back and forth turning the light on and off until she/he shoved Resident 2 onto the bed. On 5/15/25 at 1:32 PM Resident 2 stated Resident 3 was upset because she/he said the light was in her/his face and then Resident 3 shoved Resident 2 down on the bed. Resident 2 stated she/he was afraid at the time but felt safe now because the facility moved her/him out of the shared room. Resident 2 stated she/he felt abused by Resident 3 and no longer interacted with her/him. On 5/15/25 at 4:51 PM Staff 11 (LPN) stated on 4/19/25 she was called to the room Resident 2 and Resident 3 shared. Staff 11 stated Resident 3 was upset and stated she/he pushed Resident 2 because Resident 2 turned on the light. Staff 11 stated Resident 2 was upset and reported being scared.On 5/15/25 at 2:50 PM Staff 2 (DNS) stated she investigated the 4/19/25 event and concluded the incident met the definition of abuse. The deficient practice was identified as Past Noncompliance based on the following:On 4/19/25, the deficient practice was identified by the facility and was corrected when the facility implemented the following to prevent further incidents of resident to resident abuse: 1. Resident 2 and Resident 3 were separated, 2. The facility implemented auditing through alert charting, 3. The facility reviewed and updated Resident 2 and Resident 3's care plans.
Oct 2024 5 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

Based on interview and record review it was determined the facility failed to inform residents of the risks and benefits of psychotropic medication use for 1 of 5 sampled residents (#9) reviewed for m...

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Based on interview and record review it was determined the facility failed to inform residents of the risks and benefits of psychotropic medication use for 1 of 5 sampled residents (#9) reviewed for medications. This placed residents at risk for being uniformed of psychotropic medication. Findings include: Resident 9 was admitted to the facility in 8/2024 with the diagnoses including vascular dementia. The 10/22/24 Physician Orders revealed an order for Duloxetine (antidepressant)to be administered daily. The medical record revealed no evidence risk and benefit information for Duloxetine was reviewed with Resident 9. On 10/24/24 at 11:05 AM Staff 6 (LPN Resident Care Manager Support) acknowledged risk and benefit information related to the use of Duloxetine was not provided to Resident 9.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

Based on interview and record review it was determined the facility failed to assess significant weight loss for 1 of 2 sampled residents (#11) reviewed for nutrition. This placed residents at risk fo...

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Based on interview and record review it was determined the facility failed to assess significant weight loss for 1 of 2 sampled residents (#11) reviewed for nutrition. This placed residents at risk for additional weight loss. Findings include: Resident 11 admitted to the facility in 5/2023 with diagnoses of vascular dementia and malnutrition. A 5/2/23 Nutrition Care Plan revealed Resident 11 was at risk for impaired nutrition due to severe malnutrition and vascular dementia with a goal of Resident 11 maintaining or increasing her/his weight to above 167 pounds. The interventions for Resident 11 included a referral to a dietitian for evaluation and recommendations as needed. A 5/12/24 Dietitian Assessment revealed Resident 11 weighed 157.4 pounds and weight gain was beneficial. A 7/23/24 Provider Progress Note revealed Resident 11 weighed 164.9 pounds, her/his weight was stable for the last six months, no additional interventions were put in place. An 8/21/24 Provider Progress Note revealed Resident 11 weighed 164.8 pounds, her/his weight was stable for the last six months, no additional interventions were put in place. A 9/24/24 Provider Progress Note revealed Resident 11 weighed 156.4 pounds, her/his weight was down 10 pounds over the last month and seven pounds over the last six months. No additional interventions were put in place. A review of the 7/2024 through 10/2024 Progress Notes revealed no additional assessments of Resident 11's weight loss. An 10/11/24 Quarterly MDS indicated Resident 11 did not have weight loss and weighed 159 lbs. An 10/11/24 Summary Dietary revealed Resident 11 currently weighed 158.6 pounds, and over the last 180 days Resident 11 had significant weight loss. An 10/17/24 Summary Nursing assessment did not address Resident 11's weight loss. Resident 11's Weights and Vitals Summary revealed the following weights: - 4/12/24: 178.3 pounds - 7/12/24: 164.4 pounds - 9/13/24: 157 pounds - 10/11/24: 158 pounds - 10/14/24: 157.4 pounds - 10/18/24: 152.4 pounds - 10/23/24: 150 pounds On 10/22/24 at 2:48 PM Staff 6 (Resident Care Manager Support) reviewed Resident 11 and stated she did not identify weight loss on the 10/11/24 MDS but confirmed Resident 11 did have over a 10 percent weight loss in the last six months. Staff 6 stated when weight loss was identified she was to notify the provider, the family, make a registered dietitian referral, and add the resident to the Nutrition at Risk list. On 10/23/24 at 9:52 AM Staff 10 (Registered Dietitian) stated she was last at the facility on 10/18/24 and did not see Resident 11. Staff 10 stated she expected to be notified of any significant weight loss. Staff 10 confirmed she did not assess Resident 11 since 5/2024, but her/his goal was to maintain or increase her/his weight. Staff 10 stated the facility should have notified her of Resident 11's weight loss. Staff 10 stated when notified of a resident with significant weight loss she assessed her/him to see what else was going on. Staff 10 stated Resident 11 had a diagnosis of congestive heart failure so the facility needed to ensure the weight loss was not fluid related. On 10/24/24 at 11:23 AM Staff 3 (Regional RN) stated when weight loss was identified the staff were to make a referral to the registered dietitian, add the resident to nutrition at risk, and do a nutrition and weight assessment; Staff 3 confirmed these interventions were not in place for Resident 11.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

Based on interview and record review it was determined the facility failed to offer pneumococcal immunizations for 1 of 5 sampled residents (#27) reviewed for immunizations. This placed residents at r...

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Based on interview and record review it was determined the facility failed to offer pneumococcal immunizations for 1 of 5 sampled residents (#27) reviewed for immunizations. This placed residents at risk for lack of vaccination. Findings Include: Resident 27 admitted to the facility in 2/2024 with diagnoses including chronic pain. Resident 27's immunization records did not indicate if she/he was assessed for, offered, or declined a pneumococcal vaccination following admission to the facility. On 10/24/24 at 12:06 PM Staff 3 (Regional RN) stated the medical record showed no documentation the facility offered a pneumococcal vaccination to Resident 27.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined the facility failed to ensure medication storage areas were...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined the facility failed to ensure medication storage areas were secured and free of expired medication for 1 of 1 medication cart and 1 of 1 medication storage room reviewed for safe medication storage. This placed residents at risk for misappropriation of medications, adverse medication consequences and diminished treatment efficacy. Findings include: The facility's Storage of Medication Policy, revised 5/2010, stated, The Facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 1. On [DATE] at 1:49 PM the Intemediate Care medication cart outside of room [ROOM NUMBER] was unlocked and unattended. On [DATE] at 1:53 PM Staff 4 (CMA) confirmed the cart was unlocked and unattended. On [DATE] at 1:00 PM Staff 1 (Administrator) was informed of these findings. No Additional information was provided. 2. On [DATE] at 7:44 AM a multidose bottle of Lorazepam (a controlled antianxiety medication) was found in the locked medication refrigerator with an expiration date of [DATE]. On [DATE] at 7:44 AM Staff 5 (LPN) confirmed the Lorazepam was expired. On [DATE] at 1:00 PM Staff 1 (Administrator) was informed of these findings. No Additional information was provided.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review it was determined the facility failed to implement Enhanced Barrier Precautions for 1 of 1 facility reviewed for infection control. This placed resid...

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Based on observation, interview, and record review it was determined the facility failed to implement Enhanced Barrier Precautions for 1 of 1 facility reviewed for infection control. This placed residents at risk for exposure to infections. Findings include: The facility's undated Isolation - Categories of Transmission-Based Precautions policy indicated Enhanced Barrier Precautions were to be used for residents with catheters and complex wounds. On 10/21/24 Staff 1 (Administrator) provided a list of residents with catheters which included Residents 2, 8, and 14. On 10/22/24 at 12:38 PM Resident 2 and Resident 14's rooms were observed with no signage to indicate they were on Enhanced Barrier Precautions. At this time Staff 8 (CNA) stated there were no residents with precautions on the hall. On 10/22/24 at 2:10 PM Resident 8's room was observed with no signage to indicate she/he was on Enhanced Barrier Precautions. On 10/22/24 at 2:16 PM Staff 2 (DNS) stated the facility implemented Enhanced Barrier Precautions for Resident 2, Resident 8, and Resident 14 due to catheter use. Staff 2 stated there were no signs or indicators about Enhanced Barrier Precautions on the resident rooms at this time because the facility was waiting for blue sticker dots be delivered. Staff 2 further stated the facility did not store PPE in the hallways, but it was available to staff in the spa. Staff 2 went to the spa on the ICF hall to show the PPE storage and discovered the hospital gowns were not stored there. Staff 7 (CNA) offered assistance to Staff 2 and stated none of the residents on the ICF hall had precautions of any kind. Staff 2 told Staff 7 the facility were to follow Enhanced Barrier Precautions for all residents with an indwelling catheter. Staff 7 stated she was not aware and the facility staff were not doing that. Staff 2 then confirmed the facility did not implement Enhanced Barrier Precautions.
Apr 2024 2 deficiencies 1 Harm
SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Quality of Care (Tag F0684)

A resident was harmed · This affected 1 resident

Based on interview and record review it was determined the facility failed to act upon complaints of hip pain and rule out significant injury after multiple falls for 1 of 3 sampled residents (#3) rev...

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Based on interview and record review it was determined the facility failed to act upon complaints of hip pain and rule out significant injury after multiple falls for 1 of 3 sampled residents (#3) reviewed for falls. As a result, Resident 3 experienced prolonged pain over a period of four weeks, and a delay in diagnosis of hip fracture requiring hospitalization and surgery. The hip fracture was not diagnosed until 8/5/23, 31 days after her/his fall on 7/4/23. Findings include: Resident 3 was admitted to the facility in 3/2023, with diagnoses including stroke and dementia. Resident 3's care plan dated 2/28/23 noted she/he was was a fall risk due to impaired mobility, gait unsteadiness and decreased safety awareness due to her/his cognitive impairment. The care plan indicated Resident 3 had experienced falls in 3/2023 and 6/2023. Resident 3's Progress Notes revealed she/he experienced three falls on 7/4/23, 7/8/23 and 7/9/23. The 7/4/23 Post Fall Assessment revealed Resident 3 attempted to stand, fell and hit her/his head and hip and reported pain in her/his back, left side of her/his head, left hip and right shoulder. The 7/8/23 Post Fall Assessment revealed Resident 3 attempted to stand, fell and complained of pain in her/his left hip. The facility provider was notified and ordered a hip and spine x-ray. The 7/9/23 Post Fall Assessment revealed Resident 3 attempted to self transfer, fell from the chair she/he was seated in and was observed to slide to the floor by staff. Resident 3 complained of pain everywhere. On 7/11/23, a progress noted written by Staff 3 (RCM) stated the x-ray was canceled by the service provider. Resident 3's 7/2023 and 8/2023 Progress Notes documented the following dates she/he experienced pain: - 7/4/23 at 6:31 PM: Resident complained of pain - 7/4/23 at 8:59 PM: Resident had a non witnessed fall this evening. Resident stated she/he hit her/his head and hip .Resident also complained of pain to lower lateral left back and right shoulder. - 7/5/23 at 2:34 AM: Resident complained of pain all over. - 7/5/23 at 12:46 PM: Resident this morning complained of discomfort from fall, resident just had scheduled medication. - 7/6/23 at 2:10 PM: Post fall, no injuries noted, complained of leg pain. - 7/7/23 at 1:15 AM: Resident complained of pain in her/his legs. - 7/7/23 at 10:54 AM: Resident states only pain is related to her/his legs especially during wound care. - 7/8/23 at 10:38 AM: Medication given for leg pain per LN (licensed nurse). 6/10 pain scale. - 7/8/23 at 1:05 PM: Resident took a shower today, complained of legs burning after shower .There is some increased generalized weakness, accompanied by general aches/pains after shower. - 7/8/23 at 3:12 PM: Resident had a fall this afternoon during shift change. Resident was following another resident and lost her/his balance and fell in the common area. She/he did not hit her/his head, but does complain of pain in her/his left hip where she/he fell. - 7/9/23 at 4:42 AM: Resident was sleeping in the living room tonight .she/he tried to stand on her/his own and slid off the chair .Pain pill given for complaints of generalized pain. - 7/10/23 at 7:45 AM: Resident complained of 6/10 pain. - 7/11/23 at 7:46 AM: Resident complained of pain. - 7/12/23 at 12:23 PM: Post multiple falls, resident per baseline, noted pain in legs. - 7/14/23 at 4:18 PM: Resident complained of back pain. - 7/15/23 at 9:41 AM: Resident complained of pain per LN 7/10. - 7/16/23 at 8:24 AM: Resident complained of leg pain 6/10 per LN. - 7/16/23 at 12:51 PM: Resident was pulling at Unna boots, complained of burning on the right leg. - 7/17/23 at 8:30 AM: Resident complained of leg pain. - 7/18/23 at 1:51 AM: Resident complained of pain in her/his legs. - 7/19/23 at 1:51 AM: Resident complained of pain in her/his legs. - 7/19/23 at 4:57 AM: Resident appeared to be restless, she/he complained of pain in her/his legs. - 7/20/23 at 1:34 AM: Resident complained of pain in her/his legs. - 7/20/23 at 5:20 AM: Resident refused to sleep in her/his bed. She/he stated that she/he was uncomfortable in bed she/he complained of pain in her/his legs. - 7/21/23 at 2:15 AM: Resident complained of pain in her/his legs. - 7/21/23 at 4:44 AM: Resident appeared to be restless/anxious all NOC. She/he was given a snack, complained of pain in her/his legs. - 7/22/23 at 5:40 AM: Please rule out pain as contributing factor; complaint of pain when Unna boots had to be reapplied. - 7/22/24 at 10:28 AM: Resident complained of burning leg pain once during shift. - 7/22/23 at 11:11 AM: Resident complained of pain in both legs. - 7/24/23 at 1:03 AM: Resident complained of pain in her/his legs. - 7/24/23 at 9:31 AM: Resident complained of pain in both legs. - 7/24/23 at 12:42 PM: Resident up this morning, calling out for help constant, pain medications have been offered for legs pain. - 7/25/23 at 9:07 AM: Complained of leg pain. - 7/26/23 at 7:40 AM: Resident complained of pain 6/10 per LN. - 7/27/23 at 1:30 AM: Resident complained of pain in her/his legs. - 7/27/23 at 9:55 AM: PRN Administration was ineffective. Continue complaints of back pain. - 7/27/23 at 10:02 AM: Resident complained of leg pain per LN. - 7/28/23 at 1:30 AM: Resident complained of pain in her/his legs. - 7/28/23 at 4:21 PM: Resident complained of lower back pain. - 7/28/23 at 8:11 PM: Resident was observed restless this evening, frequently standing, grimacing, complained of leg pain. - 7/29/23 at 11:24 AM: Complained of leg pain. - 7/29/23 at 4:50 PM: Resident had complaint of back pain. - 7/29/23 at 7:35 PM: Resident expressed pain when staff raised legs to install new dressings. - 7/30/23 at 3:14 AM: Resident is complaining of her/his legs are burning and her/his back hurts. Medicated with PRN Norco at 11:30 PM, appears to have no effect .at this time she/he appears anxious, continuously asking us to not hurt her/him or why we hate her/him. - 7/30/23 at 12:57 PM: Resident awake all morning, constant asking for assist, crying out, trying to walk without assist in dining. - 7/31/23 at 1:43 AM: Resident complained of pain in her/his legs. - 7/31/23 at 12:19 PM: Complained of back pain. - 7/31/23 at 11:58 PM: Resident complained of pain in her/his legs. - 8/1/23 at 7:39 AM: Resident complained of pain 8/10 per LN. - 8/2/23 at 5:51 AM: Increase complained of pain noted, resident slept on and off throughout the NOC complaining of pain in her/his legs. - 8/2/23 at 8:24 AM: Report stated that patient didn't sleep well last night due to pain. Made multiple changes to RX for pain on 8/1/23, but she/he no longer has any PRN pain RX. Messaged nurse practitioner to request possible PRN. - 8/2/23 at 8:29 PM: Resident has been uncomfortable, grimacing, calling out in pain in her/his left hip and leg off and on for several hours. Occasionally re-directable but she/he returns to complaints of pain after a few minutes. She/he does not want to lay down, she/he will not keep her/his legs elevated. Family is very worried that the current dose/frequency of medication is not effective, they note she/he is rarely vocal about pain. - 8/2/23 at 10:14 PM: PRN did not control pain, resident continues to call out, wince in pain, is tense, restless. - 8/3/23 at 5:40 AM: Resident has been up all shift in her/his wheelchair .continues to call out, try to get up unassisted and call out in pain. She/he told this LN her/his pain is in the lower back, left hip or left leg at different times She/he had her/his PRN dose at 2030 but continues to complain of pain. - 8/3/23 at 2:23 PM: Resident was re-evaluated and it was determined current pain regimen was ineffective Resident was sitting in her/his wheelchair, again identifying that her/his bilateral lower extremities were in pain. - 8/3/23 at 3:39 PM: New orders to start oxycodone [a pain medication] 5 mg every 6 hours scheduled and Norco 5/325 BID for breakthrough pain. There is to be 3 hours between the oxycodone and Norco doses. - 8/4/23 at 2:58 AM: Resident appeared to be restless when assisted to bed at the beginning of this shift complaining of back pain and leg pain. - 8/4/23 at 1:53 PM: Resident anxious at times, asking staff to sit with her/him. Complaint of back pain. - 8/4/23 at 10:37 PM: Resident started fidgeting, complained of left hip pain, restless, calling out for help .Received order for left hip x-ray STAT. - 8/5/23 at 2:06 AM: X-ray results: Acute Superiorly Displaced Subcapital Fracture of the Left Femoral Neck - Orders to send to ED for evaluation and treatment. Resident 3's 7/2023 MAR documented she/he was administered PRN Norco (a pain medication) 5/325 mg a total of 42 doses on the following dates: -On 7/1/23 - 1 time; -On 7/3/23 - 1 time; -On 7/4/23 - 2 times; -On 7/5/23 - 1 time; -On 7/6/23 - 1 time; -On 7/7/23 - 1 time; -On 7/8/23 - 1 time; -On 7/9/23 - 1 time; -On 7/10/23 - 2 times; -On 7/11/23 - 1 time; -On 7/14/23 - 1 time; -On 7/15/23 - 1 time; -On 7/16/23 - 2 times; -On 7/17/23 - 1 time; -On 7/18/23 - 1 time; -On 7/19/23 - 1 time; -On 7/20/23 - 1 time; -On 7/21/23 - 2 times -On 7/22/23 - 2 times; -On 7/23/23 - 2 times; -On 7/24/23 - 2 times -On 7/25/23 - 1 time; -On 7/26/23 - 1 time; -On 7/27/23 - 2 times; -On 7/28/23 - 2 times; -On 7/29/23 - 3 times; -On 7/30/23 - 2 times; -On 7/31/23 - 3 times. Staff 3 was not available for interview during the survey period. On 4/8/24 at 9:23 AM, Witness 2 (Complainant) stated Resident 3 complained of pain while in the facility after she/he experienced several falls. Witness 2 stated she had to yell to facility staff over the phone to get x-rays and this was when the hip fracture was discovered. On 4/9/24 at 1:10 PM, Staff 1 (Administrator) and Staff 2 (DNS) stated the x-rays should have been rescheduled immediately after the service provider initially canceled on 7/11/23.
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure residents were free from physical abuse for...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure residents were free from physical abuse for 1 of 15 sampled residents (#2) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 2 was admitted to the facility in 1/2024 with diagnoses including dementia. Resident 2's most recent MDS assessment dated [DATE] revealed no BIMS score, which indicated she/he had severe cognitive impairment. Resident 2 had no behavioral issues documented. Resident 1 was admitted to the facility in 3/2022 with diagnoses including dementia and delusional disorder. Resident 1's most recent MDS assessment dated [DATE] revealed a BIMS score of 9, which indicated she/he had moderate cognitive impairment. Behaviors documented were physical and verbal symptoms directed toward others which placed other residents at significant risk of physical injury. Interventions were to remove her/him from the area and provide low stimulus diversional activities. On 2/23/24 the facility submitted a report which revealed on 2/23/24, Resident 1 was observed by staff standing over Resident 2 holding Resident 2's wrist. Resident 2 was lying on the couch in the living room. The residents were separated and Resident 2 was observed to have scratches on her/his face. On 4/8/24 at 1:20 PM Staff 7 (CNA) confirmed he was working the day of the incident. He stated Resident 1 needed close supervision due to her/his behaviors which included physical aggression toward other residents. Staff 7 stated he was on break when the incident occurred. On 4/10/24 at 11:57 AM Staff 6 (CNA) confirmed she was working the day of the incident. She stated she was in the living room with the residents and walked across the hall to wash her hands, then heard Resident 2 yelling. She ran into the living room and observed Resident 1 standing over Resident 2, who was lying on the couch. She observed Resident 1's hands to be on Resident 2's face. Staff 6 separated the residents and reported the incident to the charge nurse. Staff 6 stated she observed two skin tears on Resident 2's face as a result of Resident 1 grabbing Resident 2's face. On 4/8/24 and 4/9/24 both residents were observed and had no recall of the incident. On 4/10/24 at 1:30 PM, Staff 1 (Administrator) and Staff 2 (DNS) were notified of the investigative findings and provided no further information.
Nov 2019 3 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review it was determined the facility had a medication error rate of greater than 5%. The facility's error rate was 7.69% with two errors in 26 opportunities...

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Based on observation, interview and record review it was determined the facility had a medication error rate of greater than 5%. The facility's error rate was 7.69% with two errors in 26 opportunities. This placed residents at risk for inaccurate medication dosage. Findings include: a. Resident 5's 11/2019 MAR indicated the resident received Albuterol inhaler two puffs two times a day. On 11/25/19 the Albuterol inhaler manufacturer dosing recommendations indicated to wait one minute between each inhaler puff administered. The facility's 5/2010 policy on administering medication through a metered dose inhaler indicated to allow at least one minute between inhaler puffs. On 11/25/19 at 9:00 AM Staff 10 (CMA) was observed to administer two puffs of the Albuterol metered dose inhaler to Resident 5. The two puffs of medication were observed to be administered within five seconds between each puff. On 11/25/19 at 9:30 AM Staff 10 stated she was unaware of any spacing parameters when administering a metered dose inhaler. On 11/26/19 at 1:33 PM Staff 2 (DNS) stated her expectation and facility policy indicated there was to be a one minute wait between each inhalation of a metered dose inhaler. b. Resident 5's 11/2019 MAR indicated Resident 5 received Dulera Aerosol inhaler two puffs, two times a day. On 11/25/19 the Dulera Aerosol inhaler manufacturer dosing recommendations indicated to wait 30 seconds or more between each inhaler puff administered. The facility's 5/2010 policy on administering medication through a metered dose inhaler indicated to allow at least one minute between inhaler puffs. On 11/25/19 at 9:15 AM Staff 10 (CMA) administered two puffs of the Dulera Aerosol metered dose inhaler to Resident 5. Staff 10 administered the second dose with a two second spacing between each puff. On 11/25/19 at 9:30 AM Staff 10 stated she was unaware of any spacing parameters when administering a metered dose inhaler. On 11/26/19 at 1:33 PM Staff 2 (DNS) stated her expectation and facility policy indicated there was to be a one minute wait between each inhalation of a metered dose inhaler.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review it was determined the facility failed to ensure proper infection control during medication administration for 1 of 6 sampled residents (#5) reviewed f...

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Based on observation, interview and record review it was determined the facility failed to ensure proper infection control during medication administration for 1 of 6 sampled residents (#5) reviewed for medication administration. This placed residents at risk for cross-contamination and infection. Findings include: On 11/25/19 at 9:20 AM during medication administration Staff 10 (CMA) was observed to administer to Resident 5 Miralax (bowel medication), a medication dissolved in water, in a disposable plastic cup. Resident 5 was observed to drink one fourth of the dose. Staff 10 placed the used, contaminated, unlabeled plastic cup on the clean medication cart and walked away from the cart. On 11/25/19 at 9:30 AM Staff 10 stated she contaminated the medication cart and placed other residents at risk of cross-contamination by placing the used contaminated plastic cup on her clean medication cart. She acknowledged she intended to offer the medication to Resident 5 at later time. On 11/26/19 at 1:33 PM Staff 2 (DNS) confirmed contaminated items, such as used medication cups, were not to be placed on the clean medication cart. Staff 2 further stated she expected staff to discard medication cups immediately after use.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

Based on observation and interview it was determined the facility failed to discard expired medication for 1 of 1 medication room reviewed for medication storage. This placed residents at risk for rec...

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Based on observation and interview it was determined the facility failed to discard expired medication for 1 of 1 medication room reviewed for medication storage. This placed residents at risk for receiving ineffective medications. Findings include: On 11/22/19 at 12:26 PM the medication storage room was observed to have three unopened multi-dose bottles of Loperamide Hydrochloride suspension (medication used to treat diarrhea) with an expiration date of 10/2019 and a unopened fleet enema with an expiration date of 5/31/2019. On 11/22/19 at 12:30 PM Staff 9 (RN) confirmed three multi-dose bottles of Loperamide Hydrochloride suspension and one fleet enema were expired and were expected to be removed from the medication storage room. On 11/26/19 at 2:30 PM Staff 2 (DNS) stated her expectation was all expired medications were to be removed from the medication storage room and destroyed.
Mar 2018 2 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

Based on observation and interview it was determined the facility failed to maintain patient care equipment for 2 of 3 geri chairs observed. This placed residents at risk for injury. Findings include:...

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Based on observation and interview it was determined the facility failed to maintain patient care equipment for 2 of 3 geri chairs observed. This placed residents at risk for injury. Findings include: On 3/27/18 at 2:14 PM Resident 15's geri chair arm rest had torn vinyl and exposed metal bars and both side rails were wrapped in torn foam padding and frayed duct tape. On 3/27/18 at 3:25 PM Resident 26's geri chair arm rest had two areas of torn vinyl and exposed metal bars. On 3/27/18 at 3:30 PM Staff 6 (CNA) stated she would notify the nurse and the maintenance staff if resident care equipment was damaged or broken. On 3/27/18 at 3:40 PM Staff 7 (Activities Director) stated an internal electronic system was used to communicate maintenance needs. On 3/27/18 at 3:42 PM Staff 8 (RN) stated she would notify the DNS of damaged or broken resident care equipment. On 3/27/18 at 3:45 PM Staff 2 (DNS) stated she would expect to be notified right away of damaged or broken resident care equipment. Staff 2 viewed the damaged geri chairs and stated it had the potential to injure the resident. On 3/28/18 at 8:50 AM Staff 2 (DNS) and Staff 9 (Maintenance) stated they had not been notified of the damaged resident care equipment, either verbally or in the internal electronic system, and verified the geri chairs required repair.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review it was determined the facility failed to ensure medications were properly administered resulting in an error rate of 12.5% for 4 of 32 medication oppo...

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Based on observation, interview and record review it was determined the facility failed to ensure medications were properly administered resulting in an error rate of 12.5% for 4 of 32 medication opportunities. This placed residents at risk for unmet medication needs. Findings include: 1. Resident 31 admitted to the facility in 2017 with diagnoses including dementia. The 2/15/18 Physician Orders revealed orders for Miralax Powder (bowel care medication) 17 grams administered daily in eight ounces of fluid and Tylenol Extra Strength (pain medication) 500 mg TID. On 3/26/18 at 1:53 PM Staff 3 (CMA) administered Miralax in six ounces of apple juice and Tylenol 650 mg to Resident 31. On 3/26/18 at 2:37 PM Staff 3 acknowledged she administered the Miralax in six ounces of fluid instead of the ordered eight ounces and Tylenol 650 mg instead of the ordered 500 mg dose. 2. Resident 24 admitted to the facility in 2015 with diagnoses including diabetes. The 2/15/18 Physician Orders revealed orders for pantoprazole sodium (stomach medication) and glipizide (diabetic medication) to be administered 30 minutes before breakfast daily. On 3/28/18 at 8:38 AM Staff 4 (CMA) administered the pantoprazole sodium and glipizide and stated Resident 24 had finished her/his breakfast 15 minutes prior to the medication administration. On 3/28/18 at 10:29 AM Staff 4 acknowledged she did not administer the pantoprazole sodium and glipizide 30 minutes before breakfast as ordered.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated K - Pattern L - Widespread
Actual Harm
G - Isolated H - Pattern I - Widespread
Potential for Harm
D - Isolated E - Pattern F - Widespread
No Harm (Minor)
A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

  • "What safeguards are in place to prevent abuse and neglect?"
  • "Can I speak with families of current residents?"
  • "What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths
  • • No fines on record. Clean compliance history, better than most Oregon facilities.
  • • 27% annual turnover. Excellent stability, 21 points below Oregon's 48% average. Staff who stay learn residents' needs.
Concerns
  • • Multiple safety concerns identified: Federal abuse finding, 1 harm violation(s). Review inspection reports carefully.
  • • 13 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
  • • Grade D (48/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.

About This Facility

What is Marquis Autumn Hills Memory Care's CMS Rating?

CMS assigns MARQUIS AUTUMN HILLS MEMORY CARE an overall rating of 3 out of 5 stars, which is considered average nationally. Within Oregon, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.

How is Marquis Autumn Hills Memory Care Staffed?

CMS rates MARQUIS AUTUMN HILLS MEMORY CARE's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 27%, compared to the Oregon average of 46%. This relatively stable workforce can support continuity of care. RN turnover specifically is 62%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Marquis Autumn Hills Memory Care?

State health inspectors documented 13 deficiencies at MARQUIS AUTUMN HILLS MEMORY CARE during 2018 to 2025. These included: 1 that caused actual resident harm and 12 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Marquis Autumn Hills Memory Care?

MARQUIS AUTUMN HILLS MEMORY CARE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 39 certified beds and approximately 34 residents (about 87% occupancy), it is a smaller facility located in PORTLAND, Oregon.

How Does Marquis Autumn Hills Memory Care Compare to Other Oregon Nursing Homes?

Compared to the 100 nursing homes in Oregon, MARQUIS AUTUMN HILLS MEMORY CARE's overall rating (3 stars) matches the state average, staff turnover (27%) is significantly lower than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Marquis Autumn Hills Memory Care?

Based on this facility's data, families visiting should ask: "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the substantiated abuse finding on record.

Is Marquis Autumn Hills Memory Care Safe?

Based on CMS inspection data, MARQUIS AUTUMN HILLS MEMORY CARE has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in Oregon. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Marquis Autumn Hills Memory Care Stick Around?

Staff at MARQUIS AUTUMN HILLS MEMORY CARE tend to stick around. With a turnover rate of 27%, the facility is 19 percentage points below the Oregon average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly.

Was Marquis Autumn Hills Memory Care Ever Fined?

MARQUIS AUTUMN HILLS MEMORY CARE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Marquis Autumn Hills Memory Care on Any Federal Watch List?

MARQUIS AUTUMN HILLS MEMORY CARE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

MARQUIS AUTUMN HILLS MEMORY CARE

6630 SW BEAVERTON-HILLSDALE HWY, PORTLAND, OR 97225 | (503) 292-7874

D
Trust Grade (48/100)
3.0
CMS Rating
13
Deficiencies

Strengths

  • 4-star staffing
  • 5-star quality
  • Low turnover (27%)

Concerns

  • Abuse finding

Ask about: Abuse Safeguards, Rn Coverage

nursinghomedata.org | Data: CMS November 2025