Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Marquis Tualatin Post Acute Rehab during CMS and state inspections, most recent first.
A medication and treatment cart was found unlocked and unattended on two occasions by the same RN, contrary to the facility's policy. The RN acknowledged the oversight, and the DNS confirmed the requirement for carts to be locked when not in use.
A resident with a right femur fracture discovered a fraudulent check for $2,000 written to an agency CNA, who was assigned to them on specific dates. The check was forged and cashed without the resident's consent. The facility reported the incident to law enforcement and the Oregon Board of Nursing, but the CNA was unreachable.
A facility failed to thoroughly investigate an alleged misappropriation of property involving a resident. A fraudulent check was written from the resident's checkbook and cashed by a former agency CNA. The investigation did not include interviews with the resident or the accused, nor a review of the resident's personal inventory. This oversight was acknowledged by the facility's administrator, highlighting a risk for misuse of personal funds.
A resident's representative was not informed of a fall incident due to a lack of signed documentation, despite verbal confirmation of their role. The LPN did not notify the family, believing the resident was their own representative. The RNCM and Administrator later acknowledged the oversight, confirming the representative should have been informed.
A resident with BPH and depression required a two-person mechanical lift for transfers. After a fall from a wheelchair due to dizziness, the resident was not monitored for latent injuries as per facility protocol. Additionally, during a transfer, the resident's head was struck by a mechanical lift due to a CNA's hurried actions, and the incident was not reported to a nurse for assessment. Staff interviews confirmed these lapses in following safety procedures.
A resident with a urinary catheter experienced inadequate catheter care, leading to infection risk. Despite a care plan requiring daily cleaning, staff inconsistencies were noted, with some CNAs not performing necessary care. The resident showed symptoms of a UTI and was sent to the hospital, where issues like catheter leakage and sores were observed. Staff interviews revealed a lack of consistent care due to unfamiliarity and reliance on agency staff.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure the security of medications and biologicals, as observed during a survey. On two separate occasions, a medication and treatment cart located adjacent to the nursing station on the A-hall was found unlocked and unattended. The first incident occurred when Staff 5, an RN, left the cart unsecured while out of sight, and it was subsequently locked by Staff 6, another RN, who noticed the oversight. The second incident involved the same staff member, Staff 5, who again left the cart unlocked and unattended, only to secure it upon returning to the cart. During interviews, Staff 5 acknowledged leaving the cart unlocked and unattended, which was against the facility's policy requiring medication carts to be locked when not in use or out of the nurse's view. Staff 2, the Director of Nursing Services (DNS), was informed of these incidents and confirmed that the cart should have been locked to prevent unauthorized access to medications. These lapses in securing the medication cart placed residents at risk for unauthorized access to medications.
Misappropriation of Resident Funds by Agency CNA
Penalty
Summary
The facility failed to prevent the misappropriation of financial resources by a former agency CNA, identified as Staff 7, involving a resident who was cognitively intact. The resident, admitted with a right femur fracture, discovered a fraudulent check written from their checkbook to Staff 7 for $2,000. The check was forged and cashed while the resident was at the facility. The resident kept their checkbook in the nightstand drawer and did not authorize any staff to access it or sign checks on their behalf. The facility's investigation revealed that Staff 7 was assigned to the resident on specific dates and was asked not to return to work due to declining to care for residents. The fraudulent activity was reported to law enforcement and the Oregon Board of Nursing. Despite attempts to contact Staff 7, they were unreachable. The facility acknowledged the misappropriation of funds but noted no other reports of similar incidents.
Incomplete Investigation of Misappropriation of Resident Property
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged misappropriation of property involving a resident. The incident involved a fraudulent check written from the resident's checkbook, which was cashed by a former agency CNA. The facility's investigation was incomplete as it did not include interviews with the resident or the accused employee, nor did it review the resident's personal inventory record. Additionally, staff members who had contact with the resident were not interviewed, which was acknowledged by the facility's administrator. The resident, who was cognitively intact, was admitted with a right femur fracture and discharged shortly before the incident was reported. The facility's policy required specific steps to be taken during an investigation of misappropriation, including interviews and inventory checks, which were not followed. The failure to adhere to these procedures placed residents at risk for misuse of personal funds, as the investigation was not comprehensive enough to address all aspects of the alleged abuse.
Failure to Notify Resident's Representative of Fall Incident
Penalty
Summary
The facility failed to notify a resident's representative of a fall incident involving a resident who was admitted with diagnoses including benign prostatic hyperplasia and depression. The resident's admission record indicated that a family member, identified as Witness 15, was the resident's representative and emergency contact. However, there was no documentation in the clinical record confirming that Witness 15 had signed paperwork as the resident's representative. Witness 15 reported not being informed by the facility about the resident's fall. Staff interviews revealed that the LPN did not contact the family because the resident was considered their own representative, while the RNCM acknowledged that Witness 15 should have been notified if they were the resident's representative. The Admissions Director confirmed that Witness 15 was verbally appointed as the resident's representative during the admission process, although no paperwork was signed. The Administrator also acknowledged that Witness 15 should have been notified about the fall.
Failure to Monitor Resident After Fall and Safe Transfer
Penalty
Summary
The facility failed to ensure that a resident received appropriate care plan interventions for safe transfer and monitoring after a fall. The resident, admitted with diagnoses including benign prostatic hyperplasia and depression, required a two-person mechanical lift for transfers. On one occasion, the resident was found on the floor after falling from a wheelchair due to dizziness. Although the resident was assessed for immediate injuries, there was no documentation of monitoring for latent injuries following the fall, as expected by the facility's protocol. Staff interviews confirmed that the resident was not placed on alert charting for 72 hours post-fall, which was a standard procedure to monitor for latent injuries. Additionally, an incident occurred during a transfer using a mechanical lift, where the resident's head was struck due to the CNA operating the lift in a hurried manner. Despite the incident, the CNAs involved did not report it to a nurse, and the resident was not assessed for potential injuries. Staff interviews revealed that the incident was not communicated to the charge nurse, which was against the facility's expectations for reporting potential injuries. The administrator acknowledged these findings, indicating a lapse in following the facility's procedures for ensuring resident safety during transfers and post-fall monitoring.
Inadequate Catheter Care Leads to Infection Risk
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident, leading to an increased risk of infection. The resident, admitted with diagnoses including benign prostatic hyperplasia and hematuria, had a urinary catheter in place. The care plan required daily catheter care with soap and water and monitoring for signs of infection. However, staff interviews revealed inconsistencies in providing catheter care, with some staff admitting to not performing necessary cleaning or peri care. The resident experienced symptoms indicative of a urinary tract infection, including elevated temperatures and hematuria. A public complaint and family member testimony indicated that the resident arrived at the hospital with a leaking catheter, pain, dark cloudy urine, and sores on the genitalia. Hospital staff reported blood and discharge from the genitalia and erosion at the catheter entry point, suggesting improper catheter positioning. Staff interviews highlighted a lack of consistent catheter care, with some CNAs and LPNs acknowledging inadequate care due to unfamiliarity with residents and reliance on agency staff. The facility's administration and nursing staff recognized the deficiency, noting that catheter care was expected to be performed daily, and any issues should have been reported to the charge nurse or physician.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Tualatin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avamere Rehabilitation Of King City | 2.2 mi | — | 13 | 0 |
| Tigard Rehabilitation And Care | 3.1 mi | — | 3 | 0 |
| Pearl At Kruse Way, The | 3.9 mi | — | 3 | 0 |
| Marquis Wilsonville Post Acute Rehab | 5.5 mi | — | 3 | 0 |
| Rose Linn Care Center | 5.6 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.