Marquis Plum Ridge Post Acute Rehab

Inspectors wroteBased on interview and record review it was determined the facility failed to provide SNF ABN (Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage) notifications to 1 of 3 sampled residents (#13) reviewed for Beneficiary Notification. This placed residents and their representatives at risk for inadequate information to make financial and care decisions.

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to ensure sufficient bathing was provided to a dependent resident for 1 of 1 sampled resident (#70) reviewed for ADLs. This placed residents at risk for lack of personal hygiene.

Inspectors wroteBased on interview and record review it was determined the facility failed to clarify and follow physician orders for 1 of 5 sampled residents (#3) reviewed for medications. This placed residents at risk for delayed treatment and unmet medication needs.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide appropriate treatment and services to prevent further decrease in range of motion for 1 of 1 sampled resident (#2) who was reviewed for positioning and mobility. This placed residents at risk for contracture progression and joint pain.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure a resident who was a trauma survivor was assessed timely and received trauma-informed care for 1 of 4 sampled residents (#3) reviewed for choices. This placed residents at risk for continued traumatization.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure proper food temperatures were maintained during meal service for 3 of 13 sampled residents (#s 26, 52, and 70) reviewed for dining observations. This placed residents at risk for food that was not palatable or appetizing.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to follow proper infection control techniques during medication administration via feeding tube for 1 of 1 sampled resident (#7) reviewed for medication administration. This placed residents at risk for acquiring an infection.

Inspectors wroteBased on interview and record review it was determined the facility failed to assess the use of a physical restraints for 3 of 4 sampled residents (#s 1, 3, and 4) reviewed for elopement. This placed residents at risk for potential abuse or neglect.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure proper interventions were in place to ensure a resident remained free from accident hazards for 1 of 5 sampled residents (#1) reviewed for accidents. This placed residents at risk for accidents.

Inspectors wroteBased on interview and record review it was determined the facility failed to keep confidential all information contained in the resident's records, regardless of form for 1 of 3 sampled residents reviewed for discharge. This placed residents at risk for violation of their HIPPA privacy and security rights.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure proper food temperatures were maintained for food trays served from 1 of 1 facility kitchens reviewed for food service and for 5 of 5 residents (#s 3, 6, 23, 37 and 266) sampled for food. This placed residents at risk for food that was not palatable, safe or appetizing.

Inspectors wroteBased on interview and record review it was determined the facility failed to provide quarterly statements in writing of Personal Incidental Funds (PIF) to the resident representative for 1 of 2 sampled residents (#1) reviewed for PIFs. This placed residents at risk of being uninformed of financial statements.

Inspectors wroteBased on interview and record review it was determined the facility failed to assist residents to formulate an advanced directive for 3 of 4 sampled residents (#s 3, 7, and 37) reviewed for advance directives. This placed residents at risk for healthcare decisions to conflict with resident wishes.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were free from misappropriation of property for 1 of 2 sampled residents (#68)reviewed for abuse. This placed residents at risk for loss of property.

Inspectors wroteBased on interviews and record review it was determined the facility failed to thoroughly investigate alleged verbal abuse from staff for 1 of 2 sampled residents (#7) reviewed for abuse. This placed residents at risk for physical and verbal abuse from staff.

Inspectors wroteBased on interview and record review it was determined the facility failed to conduct quarterly care conferences as required for 3 of 3 sampled residents (#s 3, 7, and 37) reviewed for care conferences. This placed residents at risk for lack of participation in care goals and unmet needs.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure pressure injury wounds were accurately assessed, and care plans were followed for 2 of 4 sampled residents (#s 3 and 31) reviewed for pressure ulcers. This placed residents at risk for inaccurate assessment and worsening of wounds.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were free from misappropriation of property for 1 of 1 facility reviewed for misappropriation of property. This failure, determined to be a past non-compliance situation, resulted from the facility failing to ensure residents were free from misappropriation of property.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to assess a resident's ability to self-administer medications for 1 of 1 sampled resident (#45) reviewed for self-administration of medications. This placed residents at risk for improper medication administration.

Inspectors wroteBased on interview and record review it was determined the facility failed to assist residents to formulate advance directives for 2 of 4 sampled residents (#s 55 and 68) reviewed for advance directives. This placed residents at risk for healthcare decisions to be in conflict with their wishes.

Inspectors wroteBased on interview and record review it was determined the facility failed to notify a physician of an unavailable medication for 1 of 5 sampled residents (#23) reviewed for medications. This placed residents at risk for lack of adequate treatment.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident's grievance was resolved in a timely manner for 1 of 1 sampled resident (#31) reviewed for personal property. This placed residents at risk for unresolved concerns.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure a resident care plans were updated and failed to conduct a care conferences for 2 of 3 sampled residents (#s 20 and 63) reviewed for dental care, and participation in care planning. This placed residents at risk for unmet care needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident was offered to walk for 1 of 3 sampled residents (#31) reviewed for ADLs. This placed residents at risk for increased weakness.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident was provided a meaningful activity program for 1 of 3 sampled residents (#30) reviewed for activities. This placed residents at risk for lack of daily stimulation.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure medications were given per pharmacy guidelines for 1 of 1 sampled resident (#36) reviewed for antibiotics. This placed residents at risk for decreased medication efficacy (effectiveness).

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident was provided range of motion for 1 of 3 sampled residents (#30) reviewed for ADLs. This placed residents at risk for pain.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide adequate urinary care for 1 of 4 sampled residents (#23) reviewed for urinary catheters. This placed residents at risk for lack of preferred urinary care treatment.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide dialysis services for 1 of 1 sampled resident (#24) reviewed for dialysis. This placed residents at risk for unmet dialysis needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to follow up on pharmacy recommendations for 1 of 5 sampled residents (#23) reviewed for medications. This placed residents at risk for adverse medication reactions.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure the medication error rate was less than 5 percent. There were 31 medication administration observations with 12 errors; a 39 percent medication error rate. This placed residents at risk for ineffective medications.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to follow infection control standards for 3 of 4 sampled residents (#s 23, 28, and 36) reviewed for urinary devices. This placed residents at risk for urinary infection.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents received vaccines and education for 3 of 5 sampled residents (#s 16, 30, and 39) reviewed for immunizations. This placed residents at risk for infections.