Marquis Hope Village

Based on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 3 of 3 sampled CNA staff (#s 7, 8 and 9) reviewed for sufficient and competent nurse staffing. This placed residents at risk for a lack of competent staff. Findings include: A review of personnel records on 5/22/25 indicated the following employees had not received their annual performance evaluations: -Staff 7 (CNA), hired date was 2/2019 and a performance review was not completed. -Staff 8 (CNA), hired date was 1/2019 and a performance review was not completed. -Staff 9 (CNA), hired date was 4/2020 and a performance review was started in 4/2025 and not completed. On 5/23/25 at 9:45 AM PM Staff 2 (DNS) confirmed annual performance reviews were not completed for Staff 7, Staff 8 and Staff 9.

Based on observation, interview and record review it was determined the facility failed to ensure kitchen staff wore appropriate hair restraints during meal preparation and tray line for 1 of 1 facility kitchen reviewed for sanitation. This placed residents at risk for unsanitary foods and food-borne illness. Findings include: Review of the US FDA Food Code 2022 revealed: -Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food. On 5/19/25 at 9:10 AM on the initial kitchen tour observed Staff 10 (Dietary Manager) had facial hair and was observed putting breakfast items and cleaning the kitchen counters without a beard restraint in place. On 5/22/25 at 11:40 AM, Staff 10 was observed without a beard restraint while preparing lunch meals, taking food temperatures, and plating food. On 5/22/25 at 1:04 PM Staff 10 stated he expected his staff to follow hygiene protocols and wear hair restraints while working in the kitchen.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review it was determined the facility failed to identify, in a timely manner, a resident who experienced a significant change in status for 1 of 2 sampled residents (#18) reviewed for accidents. This placed residents at risk for injuries and unidentified care needs. Findings include: Resident 18 was admitted to the facility in 3/2025 with diagnoses including falls. Resident 18's 3/26/25 admission MDS indicated the resident was cognitively intact and had no behavioral symptoms, including wandering. The resident had no functional limitations and was able to use her/his upper extremity freely. A 4/30/25 Unwitnessed Fall Investigation revealed Resident 18 fractured her/his left arm when she attempted to self-transfer to the bed. A 5/1/25 progress note revealed Resident 18 was to be monitored and placed on alert charting for 14 days to determine if the resident experienced a significant change in condition. A review of Resident 18's medical record revealed no indication the resident refused care or was placed on alert charting. On 5/22/25 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 care plan interventions were in to prevent falls for 1 of 2 sampled residents (#18) reviewed for accidents. This placed residents at risk for injuries. Findings include: Resident 18 was admitted to the facility in 3/2025 with diagnoses including fracture of the humerus (a bone which connects the shoulder to the elbow). The admission MDS dated [DATE] indicated Resident 18 was cognitively intact and she/he had a history of falls with no fractures in the last six months. A review of Resident 18's medical record revealed the resident fell once on 3/28/25, twice on 4/14/25, once on 4/30/25 and once on 5/11/25. Resident 18's 5/11/25 Care Plan revealed the following: -The resident was to be seated in a high visibility area. -The resident was to have a visual cue in her/his room to remind her/him to use the call light. -The resident was on frequent checks. -The resident was not allowed to be left alone in her/his room…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 dental services were provided for 1 of 2 sampled residents (#19) reviewed for activities of daily living. This placed residents at risk for lack of dental care needs. Findings include: Resident 19 was admitted to the facility in 4/2024 with diagnoses including major depressive disorder. Resident 19's 5/24/24 Dental Care Plan revealed the following: -The resident had upper and lower dentures. -Staff were to provide the resident with oral hygiene supplies and assist with oral hygiene if she/he was too weak. -Staff were to assist with proper storage and clean the resident's dentures daily. A Social Services Quarterly assessment dated [DATE] indicated the resident had moderately impaired cognition, had no dental status changes and continued to use her/his dentures. On 5/19/25 at 3:36 PM Resident 19 was observed in bed without dentures in place. On 5/21/25 at 9:36 AM Staff 12 (CNA) stated Resident 19 had not worn her/his…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to implement enhanced barrier precautions for residents with diabetic wounds for 1 of 3 sampled residents (#2) reviewed for skin conditions. This placed residents at risk for facility acquired infections. Findings include: Resident 2 admitted to the facility on [DATE] with diagnoses including diabetic ulcers. Resident 2's 4/9/25 wound care orders instructed staff to apply idosorb 0.9% to the resident's diabetic foot ulcers, cover with gauze, and secure with a foam dressing daily. There was no evidence in Resident 2's medical record that she/he was on enhanced barrier precautions for her/his diabetic ulcers. On 4/10/25 at 11:43 AM, observation of Resident 2's wound revealed Staff 3 (LPN) did not wear a PPE gown and utilize enhanced barrier precautions when she completed wound care to the resident's three diabetic foot ulcers. On 4/10/25 at 12:57 PM, Staff 3 verified she did not wear a PPE gown when she completed Resident 2's wound care. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to ensure the Direct Care Staff Daily Report (DCSDR) postings were accurate for 9 of 30 days reviewed for staffing. This placed residents at risk for incorrect staffing information. Findings include: Review of the 11/25/23 through 12/24/23 DCSDRs indicated the following days when the number of RN staff and hours worked were inaccurate on the daily postings: -11/25/23, 12/2/23, 12/3/23, 12/9/23, 12/10/23, 12/16/23, 12/22/23, 12/23/23, 12/24/23 On 12/28/23 at 1:43 PM Staff 5 (Staffing Coordinator) stated the DCSDRs were incorrect, the facility had RNs who worked on the identified dates and was unsure why the DCSDR weekend sheets were inaccurate. On 12/29/23 at 1:56 PM Staff 1 (Administrator) acknowledged the DCSDRs were inaccurate.

Based on interview and record review it was determined the facility failed to assess a resident for safe self-administration of medication for 1 of 1 sampled resident (#26) reviewed for ADL care. This placed residents at risk for unsafe medication administration. Findings include: The facility's Self-Administration Medication policy last revised on 5/2010, indicated the following: -As part of their overall evaluation, the staff and practitioner assess each resident's mental and physical abilities, to determine whether a resident is capable of self-administering medications. -In addition, the staff and practitioner will perform a more specific skill assessment, including (but not limited to) the resident's ability to read the medication labels; comprehension of the purpose and proper dosage and administration time for her/his medications; ability to remove medications from container and to ingest and swallow them and the ability to recognize risks and major adverse consequences. -Self-administered medications must be stored in a safe and secure place, which is not accessible by other…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 Advance Beneficiary Notification (ABN) information for 1 of 3 sampled residents (#22) reviewed for discharge. This placed residents at risk for financial hardship. Findings include: Resident 22 was admitted to the facility on [DATE] with diagnoses including diabetes. The 11/30/23 NOMNC (Notice of Medicare Non-Coverage) indicated Resident 22's skilled days ended on 12/3/23. Review of Resident 22's medical record indicated the resident remained in the facility pending Medicaid. There was no documentation indicating Advance Beneficiary Notification information was provided to the resident. On 12/28/23 at 11:21 AM Staff 4 (admission Care Coordinator) stated Resident 22 was pending Medicaid and acknowledged the resident did not receive Advance Beneficiary Notification information, including the daily cost if Medicaid was not approved.

Based on interview and record review it was determined the facility failed to implement bowel care and follow physician orders timely for 2 of 5 sampled residents (#s 20 and 21) reviewed for medications. This placed residents at risk for adverse side effects and constipation. Findings include: 1. Resident 21 admitted to the facility in 11/2023 with diagnoses including chronic ulcerative colitis and dementia. A review of Resident 21's 11/29/23 admission Physician Orders revealed an order for diphenoxylate-atropine (used in the management and treatment of diarrhea) 2.5-0.025 mg, give two tablets by mouth as needed for diarrhea twice daily. A Pharmacy Recommendation dated 11/30/23 revealed Resident 21 had an order for Lomotil (diphenoxylate-atropine), which was a controlled substance medication, and noted, The pharmacy had not received a valid order and was unable to dispense the medication. Provide the pharmacy with a valid order for the medication to prevent a delay in dispensing. A Packing Slip dated 12/1/23 at 2:33 AM indicated Lomotil (diphenoxylate-atropine 2.5-0.025 mg) was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review it was determined the facility failed to provide appropriate foot care for 1 of 1 sampled resident (#26) reviewed for foot care. This placed residents at risk for lack of nail care and increased infections. Findings include: Resident 26 admitted to the facility in 11/2023 with diagnoses including stroke and depression. A 12/4/23 Progress Note indicated Staff 17 (LPN) Trimmed nail on both hands. Res requested toenails be cut, they are too thick. The resident stated her/his doctor usually did this, and [she/he] was agreeable to follow up with doctor on discharge. On 12/26/23 at 2:30 PM and 12/28/23 at 12:45 PM Resident 26's toes were observed with all toenails discolored, deformed, thickened (half-an-inch) and longer than one inch. Resident 26's right large toenail was brownish/black and the nail vertically extended above the face of the nail bed over one inch. On 12/28/23 at 12:50 PM Resident 26 stated she/he requested to have her/his toenails trimmed but it was not done. On 12/29/23 at 9:42 AM Staff 16 (LPN) stated she was aware of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure dialysis treatment and care was in place including physician orders and communication with the dialysis provider for 1 of 1 sampled resident (#1) reviewed for dialysis. This placed residents at risk for dialysis complications. Findings include: Resident 1 admitted to the facility on [DATE] with diagnoses including end stage renal disease and dependent on dialysis (a procedure to remove waste products from the blood when the kidneys stop working). a. The 11/27/23 admission MDS indicated at baseline the resident received dialysis treatments three times a week at a clinic outside the facility. Resident 1's care plan for renal failure with dialysis, created on 11/21/23, indicated treatment to the dialysis access site was to be followed per the physician orders. The 11/21/23 admission physician orders and the 12/18/23 last signed physician orders did not include any dialysis care orders. On 12/28/23 at 3:51 PM Staff 19 (RN) stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review it was determined the facility failed to ensure a medication error rate of less than five percent for 1 of 6 sampled residents (#240) reviewed for medication administration. The facility's medication error rate was 8%. This placed residents at risk for adverse medication consequences. Findings include: Resident 240 was admitted to the facility in 12/2023 with diagnoses including a fracture of the left femur (thigh bone). a. Resident 240's 12/8/23 Physician's Orders included torsemide (used to treat fluid retention) 10 mg tablet with instructions to administer 0.05 tablet daily. On 12/27/23 at 8:04 AM Staff 10 (CMA) was observed to administer torsemide to Resident 240. The torsemide 10 mg tablet was split in half prior to administration to the resident. On 12/28/23 at 12:00 PM Staff 10 acknowledged she administered Resident 240 half of the torsemide 10 mg tablet for a dose of 5 mg. She verified the order was to administer torsemide 0.05 tablet and not the 0.5 tablet which she administered to the resident. On 12/29/23 at 1:20 PM Staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to ensure CNA staff received 12 hours of in-service training annually for 2 of 5 randomly selected staff members (#s 11 and 13) reviewed for evidence of in-service training. This placed residents at risk for lack of quality care. Findings include: A review of the facility's staff training records revealed the following: -Staff 11 (CNA), hired 1/10/19, had six hours of documented training. -Staff 13 (CNA), hired 7/15/22, had one hour of documented training. On 12/29/23 at 1:26 PM Staff 5 (Staffing Coordinator) stated it was the facility's expectation that staff complete their trainings online and in person. On 12/29/23 at 1:56 PM Staff 1 (Administrator) acknowledged Staff 11 and Staff 13 did not meet the 12 hours required and provided no additional documentation.