MARQUIS VERMONT HILLS

6010 SW SHATTUCK ROAD, PORTLAND, OR 97221 (503) 246-8811
For profit - Corporation 73 Beds MARQUIS COMPANIES Data: November 2025
Trust Grade
85/100
#18 of 127 in OR
Last Inspection: December 2024

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

Overview

Marquis Vermont Hills has a Trust Grade of B+, which means it is recommended and above average compared to other facilities. It ranks #18 out of 127 nursing homes in Oregon, placing it in the top half, and #4 out of 33 in Multnomah County, indicating only three local options are better. However, the facility is experiencing a worsening trend, with issues increasing from 4 in 2022 to 12 in 2024. Staffing is a strength, with a perfect 5/5 rating and a turnover rate of 49%, which aligns with the state average, ensuring consistency in care. On the positive side, there are no fines on record, which is reassuring. However, there are some concerning incidents noted by inspectors. For instance, laundry was not processed according to hygiene standards, leaving damp linens in machines, which could lead to contamination. Additionally, food items in the kitchen were not labeled properly, risking food spoilage and potential infections. Finally, there were issues with ensuring that Advance Directives were accurately documented for residents, which could lead to incorrect medical interventions. Overall, while there are some strengths, families should weigh these concerns carefully when considering this facility for their loved ones.

Trust Score
B+
85/100
In Oregon
#18/127
Top 14%
Safety Record
Low Risk
No red flags
Inspections
Getting Worse
4 → 12 violations
Staff Stability
⚠ Watch
49% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties
✓ Good
No fines on record. Clean compliance history, better than most Oregon facilities.
Skilled Nurses
✓ Good
Each resident gets 49 minutes of Registered Nurse (RN) attention daily — more than average for Oregon. RNs are trained to catch health problems early.
Violations
⚠ Watch
16 deficiencies on record. Higher than average. Multiple issues found across inspections.
★★★★★
5.0
Overall Rating
★★★★★
5.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★★☆
4.0
Inspection Score
Stable
2022: 4 issues
2024: 12 issues

The Good

  • 5-Star Staffing Rating · Excellent nurse staffing levels
  • 4-Star Quality Measures · Strong clinical quality outcomes
  • Full Sprinkler Coverage · Fire safety systems throughout facility
  • No fines on record

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

The Bad

Staff Turnover: 49%

Near Oregon avg (46%)

Higher turnover may affect care consistency

Chain: MARQUIS COMPANIES

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 16 deficiencies on record

Dec 2024 4 deficiencies
CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review the facility failed to revise the plan of care to reflect residents' needs for 1 of 1 sampled resident (#29) reviewed for hospice. This placed residen...

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Based on observation, interview and record review the facility failed to revise the plan of care to reflect residents' needs for 1 of 1 sampled resident (#29) reviewed for hospice. This placed residents at risk for unmet care needs. Findings include: Resident 29 was admitted to the facility in 9/2023 with diagnoses of dementia and hip fracture. Resident 29's 10/15/24 Quarterly MDS indicated he/she required partial to moderate assistance with eating. Resident 29's 10/15/24 Care Plan indicated he/she required one-on-one supervision, set up, and eating assistance for all meals. Multiple random observations from 12/17/24 through 12/18/24 revealed: -12/17/24 at 10:21 AM Resident 29 was observed sitting upright in bed with a cup of ice cream placed directly in front of him/her on an overbed table without supervision. -12/17/24 at 12:28 PM Resident 29 was observed sitting upright in bed with a lunch tray placed directly in front of him/her on an overbed table without supervision during mealtimes. -12/18/24 at 8:27 AM Resident 29 was observed sitting upright in bed with a breakfast tray placed directly in front of him/her on an overbed table without supervision during mealtimes. On 12/18/24 at 8:41 AM Staff 12 (CNA) stated during mealtimes she provided frequent checks on Resident 29. Staff 12 stated she sat with him/her to assist with eating after meal tray pass had been completed and if the resident had not finished his/her meal. On 12/18/24 at 12:05 PM Staff 2 (DNS) confirmed the expectation was to provide one-on-one supervision during all meals and for staff to be present in the resident's room to ensure assistance had been provided throughout the entire meal period. On 12/19/24 at 8:55 AM Staff 11 (RCM) stated Resident 29 was care planned for one-on-one supervision at all mealtimes due to the resident's cognitive impairment and his/her pattern of sleeping through meals. Staff 11 stated it was appropriate to update Resident 29's care plan to reflect less supervision during meal times.
CONCERN (D)

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

Respiratory Care (Tag F0695)

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 obtain a physician order for a respiratory device ...

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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 obtain a physician order for a respiratory device and ensure resident respiratory equipment was maintained for 1 of 1 sampled resident (#14) reviewed for respiratory care. This placed residents at risk for increased respiratory concerns. Findings include: Resident 14 was admitted to the facility in 12/2024 with diagnoses including Alzheimer's disease and obstructive sleep apnea. The Annual MDS dated [DATE] indicated Resident 14 did not utilize a CPAP (continuous positive airway pressure) machine . A review of physician orders from 12/2024 revealed Resident 14 had no orders for use of a CPAP machine. A review of Resident 14's Care Plan and TAR from 12/2024 revealed no instructions for maintenance of the CPAP machine. On 12/17/24 at 10:41 AM Staff 5 (LPN) indicated Resident 14 used her/his CPAP machine at night. Staff 5 stated Resident 14 used her/his CPAP machine since her/his admission date and Staff 5 had cleaned it with distilled water at least two times but had no way to document the maintenance. On 12/17/24 11:10 AM Staff 3 (RNCM) confirmed Resident 14 had a diagnosis of sleep apnea and did not have a physician's order for use of a CPAP machine nor was the CPAP machine care planned to be maintained weekly. On 12/17/24 at 12:33 PM Staff 4 (NP) stated there should have been an order in place for Resident 14 prior to the CPAP machine being used.
CONCERN (D)

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

Garbage Disposal (Tag F0814)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review it was determined the facility failed to ensure the garbage area dumpsters were covered and free from debris for 1 of 1 facility dumpster reviewed for...

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Based on observation, interview and record review it was determined the facility failed to ensure the garbage area dumpsters were covered and free from debris for 1 of 1 facility dumpster reviewed for sanitation. This placed residents at risk for exposure to used medical supplies. Findings include: The facility's undated Food/Waste Disposal policy specified the following: -Dumpster lids are to be closed at all times. -Dumpster and dumpsite area is to be kept clean and free of debris. On 12/16/24 at 9:39 AM the garbage dumpster located adjacent to the kitchen's side doorway (below the facility's E hall) was observed to be open with used examination gloves, sweetener packets, paper towels, and plastic spoons scattered on the ground at the base. A CNA stood on the railed walkway above the dumpster and threw a clear plastic bag over the railing into the dumpster. Staff 7 (Dietary Manager) stated the lid was always open to allow CNAs to throw waste into the dumpster from the end of the E hallway above. She stated this was the reason for the garbage on the ground and she cleaned it every morning. Staff 7 stated she would clean the area again and keep the dumpster closed to minimize the risk of attracting vermin to the kitchen door. On 12/17/24 at 8:41 AM the same dumpster adjacent to the kitchen's side doorway was observed open with large plastic garbage bags visible inside the dumpster. On 12/17/24 at 9:45 AM the garbage dumpster was observed from the railed walkway above to be open with plastic garbage bags inside. On 12/17/24 at 2:29 PM Staff 9 (CNA) was observed with a bag of garbage in the E hallway. She opened the door at the end of the hallway, walked onto the railed walkway and threw the bag of garbage over the railing to the dumpster below. Staff 9 stated the garbage dumpster below was never closed as long as she worked in the facility. She stated she tied the bags because they contained garbage from residents' rooms including incontinence briefs. On 12/17/24 02:37 PM Staff 10 (CNA) was observed to throw a bag of garbage over the railing into the open dumpster below. Staff 10 stated she and other CNAs always threw the garbage bags over the railing and the garbage dumpster was never closed. On 12/18/24 11:26 AM Staff 7 stated she discussed the garbage dumpster situation with facility staff because they wanted to develop a way for the dumpster to be used by CNAs and kitchen staff while keeping it closed when it was not in use. On 12/19/24 at 11:57 AM Staff 1 (Administrator) acknowledged the issue with the garbage dumpster being left open and stated she expected the garbage dumpster to be kept closed and the area around it to be clean to minimize the risk of vermin being attracted to the area.
CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Based on observation, interview and record review it was determined the facility failed to ensure foods were labeled and stored in a way to minimize food spoilage in 1 of 1 kitchen reviewed for sanita...

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Based on observation, interview and record review it was determined the facility failed to ensure foods were labeled and stored in a way to minimize food spoilage in 1 of 1 kitchen reviewed for sanitation. This placed residents at risk for potential infections related to foodborne pathogens. Findings include: The facility's undated Storage of Frozen and Refrigerated Foods policy specified the following: -Food needs to be labeled with name of the product if removed from the original packaging. -No food should be stored past the expiration date. On 12/16/24 at 9:20 AM during the initial tour of the facility's kitchen, the following was observed in the walk-in refrigerator: A rolling rack containing trays of multiple undated salad items under large sheets of plastic cling film: -Partially-filled multi-use plastic bins of red beans, cottage cheese, diced hard-boiled eggs, carrots, shredded cheese; -Multi-use plastic bins of full of chopped beets, chopped bacon, garbanzo beans; -Two nearly empty multi-use plastic bins of salad dressings; and -A large multi-use plastic bin of chopped greens. On adjacent shelving, the following was observed: -A tray of 25 individually covered juice glasses on top of another tray full of similar juice glasses; and -Four trays with multiple covered disposable plastic condiment ramekins. There were no labels or dates on the items or on the trays. On 12/16/24 at 9:39 AM Staff 7 (Dietary Manager) acknowledged the items which were not labeled or dated and stated they should be labeled and dated to know when they were prepared and when they should be discarded. On 12/19/24 at 11:57 AM Staff 1 (Administrator) stated she was aware of the labeling issue and stated she expected items in the kitchen to be labeled and dated.
Jan 2024 8 deficiencies
CONCERN (D)

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

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected 1 resident

Based on interview and record review it was determined the facility failed to provide SNF ABN (Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage) information for 1 of 3 sampled resi...

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Based on interview and record review it was determined the facility failed to provide SNF ABN (Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage) information for 1 of 3 sampled residents (#28) reviewed for beneficiary notification. This placed residents at risk for unknown financial liabilities. Findings include: Resident 28 was admitted to the facility in 10/2023 with diagnoses including a fractured sacrum (back portion of the pelvis). A 12/12/23 NOMNC (Notice of Medicare Non-Coverage) indicated Resident 28's skilled days ended on 12/20/23. Review of Resident 28's health record indicated the resident remained in the facility and paid for her/his care with private funds. There was no documentation indicating Advance Beneficiary Notification information was provided to the resident so she/he understood what her/his daily out-of-pocket costs were. On 1/9/24 at 1:12 PM Staff 1 (Administrator) confirmed the facility failed to provide Advanced Beneficiary Notice information to Resident 28.
CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Based on interview and record review it was determined the facility failed to ensure dependent residents received showers for 1 of 4 sampled residents (#13) reviewed for ADLs. This placed residents at...

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Based on interview and record review it was determined the facility failed to ensure dependent residents received showers for 1 of 4 sampled residents (#13) reviewed for ADLs. This placed residents at risk for unmet ADL needs and loss of dignity. Findings include: Resident 13 was admitted to the facility in 12/2023 with diagnoses including multiple sclerosis (a progressive neurological disorder). Resident 13's 12/5/23 Bathing Care Plan indicated Resident 13 required assistance from one staff for bathing. Resident 13 preferred showers on scheduled bathing days. The facility's 1/11/24 shower schedule revealed Resident 13 received showers twice a week on Sundays and Thursdays. Resident 13's 12/14/23 through 1/7/24 bathing task logs indicated the resident received a bed bath or shower on the following days: - 12/14, 12/17, 12/25 and 1/7. A review of Resident 13's Progress Notes from 12/14/23 through 1/7/24 revealed no documentation Resident 13 was provided with additional bathing opportunities when bathing was not provided. On 1/8/24 at 11:48 AM Witness 4 (Family) reported Resident 13 received only four showers since the resident was admitted to the facility and she had to request two of the showers. On 1/11/24 at 10:25 AM Staff 8 (RN) stated residents were scheduled for two showers a week. Staff 8 stated if a resident refused or was unavailable for their shower, the resident typically had to wait until their next shower day because CNA staff were usually unable to make up missed showers. Staff 8 stated if time permitted, the evening shift was sometimes able to complete a missed shower. On 1/11/24 at 1:29 PM Staff 6 (RNCM) stated residents were supposed to receive at least two showers a week. Staff 6 reported CNA staff were extremely busy and tried to fit in additional or missed showers as they can. On 1/12/24 at 8:49 AM Staff 2 (DNS) stated she expected Resident 13 would be showered or provided a bed bath more than four times from 12/14/23 to 1/7/24.
CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review it was determined the facility failed to provide appropriate and sufficient supervision and ensure interventions were followed to reduce the risk of a...

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Based on observation, interview and record review it was determined the facility failed to provide appropriate and sufficient supervision and ensure interventions were followed to reduce the risk of accidents for 1 of 4 sampled residents (#14) reviewed for nutrition. This placed residents at risk for choking and aspiration. Findings include: Resident 14 was admitted to the facility in 12/2023 with diagnoses including stroke. Resident 14's 12/14/23 Physician Orders directed the following precautions related to the prevention of aspiration: -Provide oral care before eating or drinking, clearing secretions from the oral cavity and moistening the mouth. -Upright positioning as close as possible to a 90-degree angle. -No straws. Resident 14's 12/20/23 admission MDS revealed the resident experienced short and long term memory loss, experienced some difficulty in decision making when faced with new tasks or situations and required partial/moderate assistance with eating. The MDS also indicated the resident held food in her/his mouth/cheeks or residual food was present in her/his mouth after meals and experienced coughing or choking during meals or when swallowing medications. Resident 14's 12/21/23 Nutrition Impairment Care Plan revealed the following interventions: -Full one-to-one support with all PO intake. -Reinforce the resident should eat slowly. -Supervision for all PO intake for safety. One-to-one for all meals. -Aspiration precautions: --Provide comprehensive oral care before eating or drinking, clearing secretions from the resident's oral cavity and moistening her/his mouth. --Upright positioning at close to 90 degree angle. --Straws okay. Resident 14's 1/9/24 Dietitian Assessment indicated the resident received a regular diet with minced and moist texture (a diet requiring minimal chewing), the resident was not to use straws with thin liquids and she/he required full one-to-one support with all intake by mouth. On 1/8/24 from 12:31 PM to 12:40 PM Resident 14 was observed alone in her/his room in bed. The resident was observed to eat her/his lunch which was placed on a tray table in front of her/him. No staff were observed to supervise or reinforce to eat slowly during this time period. No coughing or choking was observed. On 1/9/24 at 8:02 AM Resident 14 was observed alone in her/his room in bed with her/his eyes closed. Resident 14's breakfast tray sat on her/his overbed table in front of the resident and her/his head of bed was elevated to approximately 30 degrees. At 8:13 AM Resident 14 opened her/his eyes and started to eat. From 8:04 AM to 8:24 AM no staff were observed to supervise or reinforce to eat slowly during this time period. No coughing or choking was observed. On 1/9/24 at 8:27 AM Staff 16 (CNA) stated she obtained information on how to care for a resident, including any mealtime precautions, from the resident's care plan. Staff 16 stated Resident 14's bed was to be all the way up when she/he ate but otherwise was not aware of any other mealtime precautions for the resident. Staff 16 stated she assisted Resident 14 with oral care after mealtimes. Staff 16 viewed Resident 14's position in bed which was how she/he was positioned during breakfast, and stated the bed was not high enough. On 1/9/24 at 8:50 AM Staff 17 (CNA) stated she obtained information on how to care for a resident, including any mealtime precautions, from the resident's care plan. Staff 17 stated staff were supposed to keep an eye on [Resident 14] and the resident was to sit as close to a 90 degree angle during mealtimes. Staff 17 also indicated the resident was okay to use straws to drink fluids, and she provided oral care to Resident 14 after meals. Staff 17 viewed Resident 14's position in bed which was how she/he was positioned during breakfast, and stated it was not adequate for mealtimes. On 1/9/24 at 9:26 AM Staff 18 (SLP) stated Resident 14 was upgraded from thickened to thin liquids on 1/8/24 and the resident was not safe to use straws when drinking thin liquids. Staff 18 stated the resident previously needed one-to-one supervision during mealtimes but now required peeking in when eating. Staff 18 further stated the resident was to be positioned upright for all meals, take small bites and eat slow. On 1/10/24 at 9:52 AM Staff 6 (RNCM) stated Resident 14 required not quite constant but intermittent supervision at mealtimes, was to be sitting as close to 90 degrees as possible when eating and was to receive oral care before eating and drinking. Staff 6 stated the resident's care plan currently indicated the need for one-to-one supervision with oral intake but he wanted to check with Staff 18 before revising the care plan. Staff 6 further stated CNAs were to follow the care plan of providing the resident with one-to-one supervision until it was updated. On 1/10/24 at 11:13 AM Staff 2 (DNS) acknowledged the findings of this investigation. Staff 2 stated she expected staff to follow the resident's care plan with regards to aspiration precautions and providing one-to-one supervision when eating and she needed to clarify the resident's use of straws.
CONCERN (D)

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

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review it was determined the facility failed to conduct timely post-dialysis assessments for 1 of 1 sampled resident (#9) reviewed for dialysis. This placed ...

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Based on observation, interview and record review it was determined the facility failed to conduct timely post-dialysis assessments for 1 of 1 sampled resident (#9) reviewed for dialysis. This placed residents at risk for unidentified complications of dialysis treatment. Findings include: Resident 9 was admitted to the facility in 12/2023 with diagnoses including diabetes and end stage kidney disease with dependence on dialysis (procedure to remove waste products from the blood). Resident 9's 12/5/23 Dialysis Care Plan indicated the resident received dialysis three times per week, had an AV fistula (a procedure that connects an artery to a vein for dialysis) in her/his left upper extremity and post-dialysis assessments were completed in order to monitor the fistula for any bleeding or swelling. On 1/10/24 at 11:54 AM Resident 9 was observed being escorted by a CNA to her/his room upon returning from dialysis. Continuous observations on 1/10/24 between 11:54 AM and 12:58 PM revealed nursing staff did not complete a post-dialysis assessment of Resident 9 upon her/his return from dialysis. On 1/10/24 at 12:58 PM Staff 8 (RN) stated she was aware Resident 9 returned from dialysis because the resident's red binder was on her desk. Staff 8 stated she typically completed a post-dialysis assessment right when a resident returned from dialysis but she did not do so this time. Staff 8 stated she should have completed the assessment within 30 minutes. On 1/12/24 at 8:49 AM Staff 2 (DNS) stated she expected dialysis residents to have a post-dialysis assessment completed within 15 minutes of their return from dialysis.
CONCERN (D)

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

Deficiency F0712 (Tag F0712)

Could have caused harm · This affected 1 resident

Based on interview and record review it was determined the facility failed to ensure residents were seen by a physician at least once every 60 days for 1 of 5 sampled residents (#15) reviewed for medi...

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Based on interview and record review it was determined the facility failed to ensure residents were seen by a physician at least once every 60 days for 1 of 5 sampled residents (#15) reviewed for medications. This placed residents at risk for unassessed and unmet needs. Findings include: Resident 15 was admitted to the facility in 4/2021 with diagnoses including Parkinson's disease. Review of Resident 15's 2023 health record revealed the resident's physician visits occurred on 5/6/23 and 10/10/23. On 1/11/24 at 10:27 AM Staff 5 (RNCM) stated she was aware physician visits were required at least once every 60 days. Staff 5 reviewed Resident 15's health record and confirmed the physician visits occurred only twice in 2023. On 1/11/24 at 1:08 PM Staff 2 (DNS) was notified of the findings of this investigation, acknowledged she was aware of the resident's situation and did not provide evidence to indicate Resident 15 was seen by the physician every 60 days. the facility proactively addressed the lack of physician visits.
CONCERN (D)

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

Deficiency F0825 (Tag F0825)

Could have caused harm · This affected 1 resident

Based on interview and record review it was determined the facility failed to provide physical therapy services as ordered for 1 of 1 sampled resident (#13) reviewed for rehabilitation services. This ...

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Based on interview and record review it was determined the facility failed to provide physical therapy services as ordered for 1 of 1 sampled resident (#13) reviewed for rehabilitation services. This placed residents at risk for reduced mobility and quality of life. Findings include: Resident 13 was admitted to the facility in 12/2023 with diagnoses including multiple sclerosis (a progressive neurological disorder). Resident 13's 12/5/23 Physician Order indicated the resident was to be evaluated and treated by PT. Resident 13's 12/5/23 Physical Therapy Evaluation and Plan of Care indicated the resident was to receive PT treatment five times a week from 12/6/23 through 3/13/24. Resident 13's PT Service Log Matrix from 12/17/23 through 12/31/23 indicated the resident received six of ten treatment sessions. On 1/8/24 at 12:24 PM Witness 4 (Family) stated the week before, during and after Christmas, Resident 13 did not receive physical therapy services at the frequency ordered because the rehabilitation department was short staffed. Witness 4 stated Resident 13 laid in her/his bed for several days in a row as a result. On 1/10/24 at 11:36 AM Staff 3 (PT) stated he had time off around the holiday and there was minimal PT coverage during that time. Staff 3 stated when he returned from his time off several residents, including Resident 13, complained they did not receive consistent PT services. On 1/10/24 at 11:56 AM Staff 4 (Physical Therapy Assistant/Rehab Director) stated she was responsible for scheduling therapy coverage. Staff 4 stated she attempted to find PT coverage for Staff 3's absence but was unable to schedule consistent PT services which resulted in reduced PT coverage during that period. On 1/12/24 at 10:33 PM Staff 2 (DNS) stated Resident 13 should have received PT services five times a week as ordered.
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 appropriate disinfection of a shared glucometer (a device used to obtain blood sugar levels) for 3 of ...

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Based on observation, interview and record review it was determined the facility failed to ensure appropriate disinfection of a shared glucometer (a device used to obtain blood sugar levels) for 3 of 5 sampled residents (#s 9, 25 and 196) observed for CBG monitoring. This placed residents at risk for the spread of bloodborne infection. Findings include: The CDC website, section titled Infection Prevention during Blood Glucose Monitoring and Insulin Administration specified there was an increased risk for exposure to bloodborne viruses through contaminated equipment, such as glucometers, when shared. Using a [glucometer] for more than one person without cleaning and disinfecting it in between uses contributed to transmission of HBV (Hepatitis B virus). [Glucometers] should be cleaned and disinfected after every use. The facility's 8/2016 Obtaining a Fingerstick Glucose Level Policy & Procedure specified the following steps in the procedure: - place the equipment on the over-bed table upon a clean/protective surface; - ensure the glucometer has been disinfected before use; - obtain a blood sample; - disinfect reusable equipment according to manufacturer's instructions. Resident 9 was admitted to the facility in 12/2023 with diagnoses including type II diabetes. Resident 25 was admitted to the facility in 12/2023 with diagnoses including type II diabetes. Resident 196 was admitted to the facility in 1/2024 with diagnoses including type II diabetes. On 1/10/24 at 11:36 AM Staff 13 (Nursing Student) gathered supplies from the medication cart, including a glucometer, entered Resident 25's room, used the glucometer and obtained Resident 25's blood sugar. Staff 13 returned to the medication cart in the hallway, placed the glucometer on the top surface of the cart and did not disinfect the glucometer. At 11:44 AM Staff 13 gathered supplies from the cart, including the used glucometer, and entered Resident 196's room. Staff 13 obtained Resident 196's blood sugar, returned to the medication cart in the hallway and placed the glucometer on the top surface of the cart. Staff 13 did not disinfect the glucometer before, during or after the process. At 1/10/24 at 11:51 AM Staff 13 gathered supplies from the medication cart, including the used glucometer and began to enter Resident 9's room. Staff 13 realized Resident 9 was out of the facility at an appointment and stated she was unable to obtain the resident's blood sugar. Review of Resident 25's and Resident 196's health record revealed no diagnoses including viral bloodborne pathogens. On 1/10/24 at 11:59 AM Staff 13 stated she performed tasks as a student nurse in the facility since 12/2023. When asked about the process and frequency for glucometer disinfection, Staff 13 responded she knew it needed to be cleaned with this and pointed to the container of Super Sani-Cloth Sanitizing wipes on the medication cart and she was unsure how often the glucometers were to be disinfected. On 1/11/24 at 12:57 PM Staff 2 (DNS) stated the disinfection process for shared glucometers included the use of the Super Sani-Cloth Sanitizing wipes. Staff 2 stated the glucometer was to be wiped thoroughly and staff were to wait two minutes before using the glucometer on the next resident. Staff 2 was notified about the lack of glucometer disinfection between residents and stated her expectation was to disinfect between each resident use.
CONCERN (E)

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

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

Based on interview and record review it was determined the facility failed to ensure records were accurate for 4 of 4 sampled residents (#s 8, 18, 25 and 26) reviewed for Advance Directives. This plac...

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Based on interview and record review it was determined the facility failed to ensure records were accurate for 4 of 4 sampled residents (#s 8, 18, 25 and 26) reviewed for Advance Directives. This placed residents at risk for inaccurate medical interventions. Findings include: 1. Resident 8 was admitted to the facility in 9/2023 with diagnoses including Parkinson's disease. A 12/19/23 Multidisciplinary Care Conference report documented Resident 8 had an Advance Directive and a copy was in the clinical records. On 1/9/23 at 1:26 PM Staff 12 (Social Services Director) confirmed Resident 8 was documented as having a copy of an Advance Directive on file with the facility, but Resident 8 did not have an Advance Directive on file at the facility. On 1/9/23 at 2:33 PM Resident 8 stated she/he did not have an Advance Directive and did not provide an Advance Directive to the facility. 2. Resident 18 was admitted to the facility in 2/2020 with diagnoses including kidney failure. A 12/29/23 Multidisciplinary Care Conference report documented Resident 18 had an Advance Directive and a copy was in the clinical records. On 1/9/23 at 1:26 PM Staff 12 (Social Services Director) confirmed Resident 18 was documented as having a copy of an Advance Directive on file with the facility, but Resident 18 did not have an Advance Directive on file at the facility. On 1/9/23 at 2:45 PM Resident 18 stated she/he did not have an Advance Directive and did not provide an Advance Directive to the facility. 3. Resident 25 was admitted to the facility in 12/2023 with diagnoses including congestive heart failure. A 12/20/23 Multidisciplinary Care Conference report documented Resident 25 had an Advance Directive and a copy was in the clinical records. On 1/9/23 at 1:26 PM Staff 12 (Social Services Director) confirmed Resident 25 was documented as having a copy of an Advance Directive on file with the facility, but Resident 25 did not have an Advance Directive on file at the facility. On 1/10/23 at 9:50 AM Resident 25 stated she/he did not have an Advance Directive and did not provide an Advance Directive to the facility. 4. Resident 26 was admitted to the facility in 12/2023 with diagnoses including spinal cord compression. A 12/8/23 Multidisciplinary Care Conference report documented Resident 26 had an Advance Directive and a copy was in the clinical records. On 1/9/23 at 1:26 PM Staff 12 (Social Services Director) confirmed Resident 26 was documented as having a copy of an Advance Directive on file with the facility, but Resident 26 did not have an Advance Directive on file at the facility. On 1/9/23 at 2:21 PM Resident 26 stated she/he did not have an Advance Directive and did not provide an Advance Directive to the facility.
Dec 2022 4 deficiencies
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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based on observation interview and record review it was determined the facility failed to follow physician orders for 1 of 1 sampled resident (#10) reviewed for non-pressure skin conditions. This plac...

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Based on observation interview and record review it was determined the facility failed to follow physician orders for 1 of 1 sampled resident (#10) reviewed for non-pressure skin conditions. This placed residents at risk for worsening skin conditions. Findings include: Resident 10 admitted to the facility in 10/2022 with diagnoses including cholecystectomy (removal of gallbladder). The 12/7/22 physician order indicated Resident 10 was to receive the following treatment: *Cleanse drain site to abdomen, pat dry, apply skin protectant and replace split gauze and secure with paper tape every evening shift and PRN. On 12/13/22 at 1:07 PM Resident 10 was observed to have a dressing on the right side of the lower abdomen covered by a dressing. The dressing was observed to have staff 10 (LPN) initials and was dated 12/11/22. The 12/2022 TAR indicated Resident 10 received a dressing change from Staff 4 (LPN) on 12/12/22. On 12/13/22 at 2:14 PM Staff 4 stated she thought the dressing was to be changed every two days and did not recall changing it on 12/12/22. Staff 4 confirmed the observed dressing was initialed by Staff 10 and dated 12/11/22. Staff 4 confirmed she documented a dressing change was completed on 12/12/22, did not complete the dressing change on 12/12/22 and acknowledged the physician orders were not followed. On 12/13/22 at 2:24 PM Staff 2 (DNS) acknowledged the findings and stated the expectation was for staff to complete treatments before signing the TAR and follow physician orders for treatments.
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

Pressure Ulcer Prevention (Tag F0686)

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 received pressure ulcer treatment...

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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 received pressure ulcer treatments for 1 of 1 sampled resident (#18) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include: Resident 18 was admitted to the facility in 5/2022 with diagnoses including diabetes. Resident 18 was hospitalized from [DATE] to 12/8/22. The 12/8/22 hospital orders indicated Resident 18 had a pressure ulcer to the sacral area and to follow standard nursing protocols for wound care. Wound Evaluations indicated Resident 18 had a Stage 2 pressure ulcer to the coccyx with the following measurements with no indication the wound worsened: *11/28/22 3.51 cm x 2.17 cm x 0.0 cm. *12/9/22 3.09 cm x 2.23 cm x 0.1 cm. *12/16/22 1.11 cm x 2.64 cm x 0.0 cm. The 12/2022 TARs indicated Resident 18 did not receive dressing changes from 12/8/22 through 12/19/22. On 12/20/22 at 9:11 AM Resident 18 declined to allow staff to complete a dressing change or wound measurements. On 12/20/22 at 10:23 AM Staff 2 (DNS) stated Resident 18 readmitted to the facility on [DATE] and acknowledged there was no indication treatment orders were received or implemented until 12/19/22. Staff 2 stated the expectation was for the charge nurse to implement wound care orders when Resident 18 readmitted to the facility on [DATE].
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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**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 interventions were implemente...

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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 interventions were implemented to prevent falls for 1 of 2 sampled residents (#8) reviewed for falls. This placed residents at risk for injury. Findings include: Resident 8 admitted to the facility on [DATE] with diagnoses including dementia and a stroke with left sided weakness. The 11/10/22 admission MDS indicated Resident 8 was severely cognitively impaired and had a history of falls. The Fall Care Plan, last revised 12/13/22, indicated Resident 8 had multiple falls related to her/his diagnoses. Interventions did not include the resident having two fall mats on both sides of her/his bed until 12/16/22. Fall Investigations were reviewed for 12/8/22, 12/9/22, 12/10/22, and 12/14/22 and indicated fall mats were to be in place for Resident 8. On 12/16/22 the following interviews were conducted with staff related to Resident 8's falls: *11:11 AM Staff 7 (CNA) stated Resident 8 was impulsive and often tried to self-transfer out of bed. Staff 6 stated interventions included for the resident to have fall mats in place when she/he was in bed. *11:27 AM Staff 8 (LPN) stated Resident 8 would forget she/he had left sided weakness and would slide out of bed. Staff 8 stated fall mats were to be on both sides of the resident's bed to prevent injury. *12:43 PM Staff 9 (CNA) stated Resident 8 often self-transferred and interventions to prevent falls included fall mats on both sides of the resident's bed. On 12/14/22 at 1:44 PM and 12/16/22 at 12:50 PM Resident 8 was observed in bed and there were no fall mats on the floor. The fall mats were observed rolled up against the wall. On 12/16/22 at 12:51 PM Staff 9 (CNA) confirmed Resident 8's fall mats were not on the floor on either side of the resident's bed and were expected to be in place when the resident was in bed. On 12/16/22 at 1:26 PM Staff 6 (RNCM) stated the resident was expected to have fall mats in place on both sides of the bed when the resident was in bed. Staff 6 stated the first fall mat was implemented shortly after the resident's admission and the second fall mat was added 12/14/22. Staff 6 acknowledged Resident 8's care plan did not include the interventions for fall mats.
CONCERN (F) 📢 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

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

Based on observation and interview, it was determined the facility failed to process laundry in accordance with accepted national standards in order to produce hygienically clean laundry and prevent t...

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Based on observation and interview, it was determined the facility failed to process laundry in accordance with accepted national standards in order to produce hygienically clean laundry and prevent the spread of infection to the extent possible for 2 of 2 laundry washing machines reviewed for infection control. This placed residents at risk of contaminated laundry. The findings include: According to the Center for Disease Control and Prevention: Guidelines for Environmental Control in Healthcare Facilities (2003); Laundry and Bedding Section G.II.D: -Do not leave damp textiles or fabrics in machines overnight. During an observation on 12/14/22 at 1:44 PM wet laundry including linens and towels was observed in both washing machines. Condensation was visible on the inside of door windows and the wash cycles were complete. On 12/14/22 at 1:56 PM Staff 11 (HR/Staffing) stated Staff 12 (Laundry) worked from 4:00 AM until 12:30 or 1:00 PM. She confirmed laundry staff was gone for the day and would not return until the morning of 12/15/22. In an interview on 12/15/22 at 9:20 AM Staff 12 (Laundry) stated she left the wet laundry in the washers overnight from 12/14/22 until the beginning of her shift on 12/15/22 at about 5:00 AM when she transferred the wet laundry to the dryers. She confirmed she normally left wet laundry in the large washing machine overnight. She stated she did not rewash the laundry before transferring it to the dryers. In an interview on 12/15/22 at 2:16 PM Staff 1 (Director of Operations) was advised of these findings. He reported he did not know wet laundry could not be left in the washers overnight.
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

  • "Can I speak with families of current residents?"
  • "What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths
  • • Grade B+ (85/100). Above average facility, better than most options in Oregon.
  • • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
  • • No fines on record. Clean compliance history, better than most Oregon facilities.
Concerns
  • • 16 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Generally positive indicators. Standard due diligence and a personal visit recommended.

About This Facility

What is Marquis Vermont Hills's CMS Rating?

CMS assigns MARQUIS VERMONT HILLS an overall rating of 5 out of 5 stars, which is considered much above average nationally. Within Oregon, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.

How is Marquis Vermont Hills Staffed?

CMS rates MARQUIS VERMONT HILLS's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 49%, compared to the Oregon average of 46%.

What Have Inspectors Found at Marquis Vermont Hills?

State health inspectors documented 16 deficiencies at MARQUIS VERMONT HILLS during 2022 to 2024. These included: 16 with potential for harm.

Who Owns and Operates Marquis Vermont Hills?

MARQUIS VERMONT HILLS is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by MARQUIS COMPANIES, a chain that manages multiple nursing homes. With 73 certified beds and approximately 46 residents (about 63% occupancy), it is a smaller facility located in PORTLAND, Oregon.

How Does Marquis Vermont Hills Compare to Other Oregon Nursing Homes?

Compared to the 100 nursing homes in Oregon, MARQUIS VERMONT HILLS's overall rating (5 stars) is above the state average of 3.0, staff turnover (49%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.

What Should Families Ask When Visiting Marquis Vermont Hills?

Based on this facility's data, families visiting should ask: "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?"

Is Marquis Vermont Hills Safe?

Based on CMS inspection data, MARQUIS VERMONT HILLS has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 5-star overall rating and ranks #1 of 100 nursing homes in Oregon. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Marquis Vermont Hills Stick Around?

MARQUIS VERMONT HILLS has a staff turnover rate of 49%, which is about average for Oregon nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Marquis Vermont Hills Ever Fined?

MARQUIS VERMONT HILLS 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 Vermont Hills on Any Federal Watch List?

MARQUIS VERMONT HILLS 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.