Marquis Springfield

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a homelike environment for 1 of 1 facility reviewed for environment. This placed residents at risk for not having a homelike environment.

Inspectors wroteBased on record review and interview the facility failed to provide residents with a risk benefit assessment for 1 of 1 resident (# 74) assessed for food. This place residents at risk for uninformed choices.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident's skin injury was investigated for 1 of 3 sampled residents (#77) reviewed for non-pressure skin injury. This placed residents at risk for worsening wounds.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were given bed hold information for 2 of 2 sampled residents (#s 2 and 31) reviewed for hospitalization. This placed residents at risk for lack of information and unexpected financial costs.

Inspectors wroteBased on observation, interview and record review the facility failed to provide meaningful activities designed to meet the interests of the resident for 1 of 1 resident (# 14) reviewed for mood. This placed residents at risk for decreased quality of life.

Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders and implement non-pressure injury interventions for 1 of 3 sampled residents (#77) reviewed for edema. This placed residents at risk for fluid overload and worsening wounds.

Inspectors wroteBased on observations, interviews, and record review it was determined the facility failed to ensure medications were not left at a resident's bedside, residents were monitored after an aspiration event, and fall interventions were in place for 3 of 7 sampled residents (#s 5, 43 and 83) reviewed for accidents and nutrition. This placed residents at risk for accidental poisoning, aspiration, and at risk for injuries from falls.

Inspectors wroteBased observations, interviews, and record review it was determined the facility failed to maintain healthy nutrition status for 3 of 7 sampled residents (#s 12, 13, and 96) reviewed for pressure ulcers, tube feeding, and nutrition. This placed residents at risk for impaired nutrition.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents did not display increased anger, withdrawal or depressive behaviors for 1 of 1 resident (# 14) reviewed for mood. This placed residents at risk for unidentified depression.

Inspectors wroteBased on interview and record review it was determined the facility failed to follow medication parameters for 1 of 5 sampled residents (#5) reviewed for medications. This placed residents at risk for side effects to medications.

Inspectors wroteBased on observation interview and record review it was determined the facility failed to ensure an insulin open date was documented for 1 of 1 sampled resident (#17) observed to receive insulin during medication administration observation. This placed residents at risk for ineffective medication regimen.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure the influenza vaccine was offered to residents for 1 of 5 (#13) sampled residents reviewed for vaccinations. This placed residents at risk for influenza infection.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure residents had an accessible bathroom call light for 2 of 3 sampled residents (#s 38 and 83) reviewed for accidents. This placed residents at risk for the inability to call for assistance.

Inspectors wroteBased on interview and record review it was determined the facility failed to protect residents' rights to be free from misappropriation of property by staff for 4 of 4 sampled residents (#101, 102, 103 and 104) reviewed for misappropriation of property.

Inspectors wroteBased on interviews and record reviews it was determined the facility failed to report a reasonable suspicion of a crime to the State Survey Agency for 4 of 4 sampled residents (#s 101,102, 103 and 104) reviewed for misappropriation of property. This placed residents at risk for further misappropriation of property and incomplete investigations.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents were treated with dignity for 1 of 1 sampled resident (#137) reviewed for dignity, 3 of 15 residents (#s 2, 15 and 39) reviewed for assisted dining. This placed residents at risk for lack of dignity.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure resident dining environments were homelike, and resident shower rooms were clean for 1 of 2 dining rooms and 5 of 5 shower rooms reviewed for environment. This placed residents at risk for lack of homelike environment and an unsanitary environment.

Inspectors wroteBased on observation, interview and record review it was determine the facility failed to ensure a residents call light was within reach for 1 of 2 sampled residents (#25) reviewed for physical environment. This placed residents at risk for lack of ADL assistance.

Inspectors wroteBased on interview and record review it was determined the facility failed to provide information related to financial responsibilities for 1 of 3 sampled residents (#14) reviewed for Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN). This placed residents at risk for unforeseen financial responsibilities.

Inspectors wroteBased on interview and record review it was determined the facility failed to comprehensively assess a resident's needs related to nutrition for 2 of 3 sampled residents (#s 17 and 42) reviewed for nutrition. This placed residents at risk for unmet nutritional needs and weight loss.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to implement a mobility device for 1 of 2 sampled residents (#37) reviewed for positioning and mobility. This placed residents at risk for functional decline.

Inspectors wroteBased on observation, interview, and record review the facility failed to evaluate the potential risk of choking related to altered swallowing ability for 1 of 3 sampled residents (#430) reviewed for nutrition. This placed residents at risk for choking.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure dialysis services were in place including transportation, monitoring and communication with the dialysis provider for 1 of 1 sampled resident (#17) reviewed for dialysis. This placed residents at increased risk for complications associated with dialysis treatment.

Inspectors wroteBased on interview and record review the facility failed to ensure residents did not receive unnecessary steroid medication for 1 of 6 sampled residents (#15) reviewed for unnecessary medications. This placed residents at risk for adverse medication consequences.

Inspectors wroteBased on interview and record review it was determined the facility failed to have a dialysis contract in place for 1 of 1 sampled resident (#17) reviewed for dialysis. This placed residents at risk for not receiving appropriate dialysis services.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure a medication error rate of less than 5% (5 errors in 31 opportunities resulting in a 16.13% error rate) for 3 of 4 sampled residents (#s 6, 9 and 55) observed for medication administration. This placed residents at risk for medication errors.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to accurately assess dental status for 1 of 2 sampled residents (#58) reviewed for dental. This placed residents at risk for lack of dental services.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide ADL care for 1 of 3 sampled residents (#5) reviewed for ADLs. This placed residents at risk for poor hygiene.

Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders for 3 of 6 sampled residents (#s 55, 182, and 189) reviewed for medications and notification. This placed residents at risk for unmet needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to prevent and accurately and comprehensively assess pressure ulcers for 2 of 5 sampled residents (#s 2 and 186) reviewed for pressure ulcers. This placed residents at risk for pressure ulcers.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure the environment was free of accident hazards for 3 of 3 sampled residents (#s 31, 51 and 182) reviewed for accidents and smoking. This placed residents at risk for injury.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide oxygen therapy according to physician's orders for 1 of 1 sampled resident (#283) reviewed for respiratory services. This placed residents at risk for unmet respiratory needs.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 4 sampled residents (#55) observed for medication administration. This placed residents at risk for medication complications or adverse side effects.