Marquis Plaza Regency Post Acute Rehab

Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure adequate supervision and appropriate post fall assessment following an unwitnessed fall of a resident identified as high risk for falls. The facility failed to recognize and respond in a timely manner to a significant change in condition, did not initiate required frequent and systematic neurological assessments, and did not ensure timely medical evaluation for 1 of 7 sampled residents (Resident 1). This deficient practice resulted in a delay in the identification and treatment of a serious head injury, as evidenced by findings of a left subdural hematoma (blood collecting between the brain and its covering on the left side) and subarachnoid hemorrhage (bleeding in the space around the brain), resulting in actual harm to the resident.

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR- a federally mandated process which screens individuals seeking admission to a nursing facility (NF) to identify those with serious mental illnesses (SMI) or intellectual/developmental disabilities (ID/DD) to ensure individuals with these conditions receive the most appropriate placement) level II was completed for 1 of 40 sampled residents (Resident 155). The deficient practice had potential for not ensuring a resident with behavioral symptoms still fits within the resident population and for additional behavioral needs would be provided.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure a baseline care plan was developed and implemented for residents who were admitted with a peripherally inserted central catheter (PICC) line for 2 of 40 sample residents (Residents 159 and 164). The deficient practice had the potential to place the residents at risk of receiving inadequate PICC line care which could have resulted in complications such as infection and line occlusion.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure fingernail care was provided for 1 of 40 sampled residents (Resident 147). The deficient practice had the potential for residents not to receive nail care.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure care orders were transcribed and carried out for a peripherally inserted central catheter (PICC) line for 2 of 40 sampled residents (Residents 159 and 164) and a short peripheral line was dated, and maintenance protocols were followed during non-use for 1 of 40 sampled residents (Resident 162). The deficient practice had the potential to place residents at risk of infection.

Inspectors wroteBased on observation, interview, record review and document review the facility failed to ensure physician orders with therapy settings were obtained and a comprehensive care plan developed for 1 of 40 sampled residents (R172) receiving Continuous Positive Airway Pressure (CPAP- a medical device used to help people breathe more easily during sleep) treatment. The deficient practice had the potential to result in inappropriate or ineffective treatment for residents receiving CPAP therapy.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure the temperature in a resident's personal refrigerator was monitored for two unsampled residents (Residents 63 and 94). The deficient practice had the potential for foods to be stored at temperatures which could lead to food borne illness.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to notify the resident representative of an incident, and a skin tear identified for 1 of 5 sampled residents (Resident 1). The deficient practice had the potential to deprive the resident's representative the right to be informed of changes to the resident's health status.

Inspectors wroteBased on clinical record review, interview, and document review, the facility failed to ensure Comprehensive Care Plans included a care plan related to 1) the care and treatment for constipation (Resident #24), 2) the care and treatment of insomnia and constipation (Resident #134), 3) the care and treatment of edema (Resident # 134), and 4) the care and treatment of post-traumatic stress disorder (PTSD) (Resident #28) to include goals, preferences, needs, and interventions, for 4 of 29 sampled residents. The deficient practices had the potential to deprive residents of necessary care and treatments.

Inspectors wroteBased on clinical record review, document review, and interview, the facility failed to complete a discharge summary by the primary care provider to include the recapitulation of the resident's stay and the treatment and services obtained at the facility for 1 of 2 sampled closed records (Resident #142). The deficient practice has the potential to impact the resident not receiving the appropriate post discharge care, medications or treatments.

Inspectors wroteBased on observation, clinical record review, interview, and document review the facility failed to ensure a wound care nurse followed physician orders for 1 of 29 sampled residents (Resident #61). The deficient practice had the potential to place the resident at risk for delayed healing of a wound. Resident #61 Resident #61 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing. A Skin Wound Assessment form dated 09/18/2024, documented Resident #61 had a facility acquired unstageable pressure injury (PI) to the front of the resident's right knee. The wound measured 0.9 cm area, 1.2 cm length x 1.1 cm width. The PI was documented as healing slowly or stalled but stable. [...]

Inspectors wroteBased on clinical record review, document review, and interview, the facility failed to ensure licensed staff did not jeopardize a resident's hemodialysis catheter for 1 of 29 sampled residents (Resident #57). This deficient practice may have placed the patient at risk for delays in dialysis treatments, unnecessary discomfort and medical/surgical interventions.

Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to ensure medication was administered with an error rate less than 5 percent (%). There were 27 opportunities and 7 medication errors. The medication error rate was 25.93%.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure 1 of 5 residents reviewed for vaccinations, including pneumococcal vaccines (Residents #66) was screened for eligibility to receive a pneumococcal vaccine, education regarding the vaccine was provided to the resident and/or the resident representative, and the indicated pneumococcal vaccine was offered and either administered or declined. The deficient practice may have placed the resident at risk for not being protected against serious illness.

Inspectors wroteBased on interview, record review and document review, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form to 1 of 3 discharged residents (Resident 81). The deficient practice deprived the residents of their right to be informed of their Medicare coverage status and the appeal process.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure two-person assistance during incontinence care was provided as planned to prevent falls for 1 of 27 residents (Resident 289). This deficient practice led to a resident's fall with injury.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure a care plan was accurately developed in accordance with the resident's assessment for 1 of 27 residents (Resident 124). Specifically, the resident's assessment reflected the resident required extensive assistance by two persons for bed mobility, and toileting but the care plan failed to specify the resident required two-person assistance. The deficient practice resulted in a fall incident with minor injury during provision of care.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure physician orders for the care and maintenance of a suprapubic catheter (flexible tube used to drain urine from the bladder) were obtained for 1 of 27 sampled residents (Resident 389). The deficient practice had the potential to lead to infection and complications associated with catheter use.