Marquis Autumn Hills Memory Care

Based on observation, interview, and record review it was determined the facility failed to provide functional call lights for 3 of 3 sampled residents (#s 20, 21, and 26) reviewed for accommodation of needs. This placed residents at risk for not being able to call for assistance. Findings include: The facility's 1/2016 Assessment for Ability to Make Use of Electric Call System policy instructed facility staff to assess residents for call light use at admission and when a significant change occurred. The policy instructed facility staff to document identified call light safety risks in the resident's record.a. Resident 20 was admitted to the facility in 2/2024 with diagnoses including unspecified dementia.Resident 20's 8/30/25 revised care plan revealed she/he used a pressure sensitive call light pad. b. Resident 21 was admitted to the facility in 8/2025 with diagnoses including unspecified dementia and repeated falls.Resident 21's 2/14/26 revised care plan did not include information related to call light use. c. Resident 26 was admitted to the facility in 6/2019 with diagnoses…

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 provide adequate monitoring of antipsychotic medication use for 1 of 5 sampled residents (#16) reviewed for medications. This placed residents at risk for adverse side effects of antipsychotic medication. Findings include: Resident 16 was admitted to the facility on [DATE] with diagnoses including vascular dementia with agitation and depression.A 1/12/26 physician order revealed Resident 16 was prescribed quetiapine 75 MG (an antipsychotic medication) twice daily.A review of Resident 16's medical record revealed no indication an Abnormal Involuntary Movement Scale (AIMS) (used to identify if symptoms/side effects of psychoactive medication use were present) assessment was completed.On 2/26/26 at 3:58 PM Staff 2 (RNCM/DNS/IP) stated Resident 16 was already on an antipsychotic medication upon admission, so her understanding was Resident 16 did not require an AIMS completed until six months after admission.On 2/26/26 at 4:10 PM Staff 11…

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 assistance was provided with dressing and personal hygiene for 1 of 3 sampled residents (#9) reviewed for ADLs. This placed residents at risk for poor hygiene. Findings include:Resident 9 was admitted to the facility on [DATE] with diagnoses including delusional disorders.The 2022 [NAME] Standards of Care indicated the following:-Staff were required to change residents' clothing each day. -Staff were required to shave residents as needed. The 10/2025 Care Plan indicated the following:-Resident 9 required supervision and assistance to complete dressing.-Ensure clothing and footwear was clean.-Provide assistance with dressing after resident attempted each step. -Pick out a couple appropriate outfits and offer me choices.The Kardex indicated Resident 9 required constant supervision with cueing and minimal physical assistance during shaving.The 11/2025 Quarterly MDS indicated Resident 9 had a BIMS score of 6 which…

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 honor the resident's right to be free from physical abuse from other residents for 1 of 6 sampled residents (#2) reviewed for abuse. This placed residents at risk for physical abuse. Findings include: Resident 2 admitted to the facility in 3/2025 with diagnoses including Alzheimer's disease. Resident 2's 3/17/25 admission MDS revealed she/he had a BIMS of 9, which indicated moderate cognitive impairment.Resident 3 admitted to the facility in 8/2023 with diagnoses including dementia.Resident 3's 2/24/25 Quarterly MDS revealed she/he had a BIMS of 12, which indicated moderate cognitive impairment.An 4/19/25 facility Investigation Summary and Conclusion revealed on the morning of 4/19/25 Resident 2 and Resident 3 were in their shared room asleep when Resident 2 woke up and turned on the overhead light. Resident 3 woke up and became angry, swore at Resident 2, and pushed her/him back onto her/his bed. Resident 3 then went to the common television room to complain about the overhead light being on. The facility…

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 medication storage areas were secured and free of expired medication for 1 of 1 medication cart and 1 of 1 medication storage room reviewed for safe medication storage. This placed residents at risk for misappropriation of medications, adverse medication consequences and diminished treatment efficacy. Findings include: The facility's Storage of Medication Policy, revised 5/2010, stated, The Facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 1. On [DATE] at 1:49 PM the Intemediate Care medication cart outside of room [ROOM NUMBER] was unlocked and unattended. On [DATE] at 1:53 PM Staff 4 (CMA) confirmed the cart was unlocked and unattended. On [DATE] at 1:00 PM Staff 1 (Administrator) was informed of these findings. No Additional information was provided. 2. On [DATE] at 7:44 AM a multidose bottle of Lorazepam (a controlled antianxiety medication) was found in the locked medication…

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 implement Enhanced Barrier Precautions for 1 of 1 facility reviewed for infection control. This placed residents at risk for exposure to infections. Findings include: The facility's undated Isolation - Categories of Transmission-Based Precautions policy indicated Enhanced Barrier Precautions were to be used for residents with catheters and complex wounds. On 10/21/24 Staff 1 (Administrator) provided a list of residents with catheters which included Residents 2, 8, and 14. On 10/22/24 at 12:38 PM Resident 2 and Resident 14's rooms were observed with no signage to indicate they were on Enhanced Barrier Precautions. At this time Staff 8 (CNA) stated there were no residents with precautions on the hall. On 10/22/24 at 2:10 PM Resident 8's room was observed with no signage to indicate she/he was on Enhanced Barrier Precautions. On 10/22/24 at 2:16 PM Staff 2 (DNS) stated the facility implemented Enhanced Barrier Precautions for Resident 2, Resident 8, and Resident 14 due to catheter use. Staff 2…

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 inform residents of the risks and benefits of psychotropic medication use for 1 of 5 sampled residents (#9) reviewed for medications. This placed residents at risk for being uniformed of psychotropic medication. Findings include: Resident 9 was admitted to the facility in 8/2024 with the diagnoses including vascular dementia. The 10/22/24 Physician Orders revealed an order for Duloxetine (antidepressant)to be administered daily. The medical record revealed no evidence risk and benefit information for Duloxetine was reviewed with Resident 9. On 10/24/24 at 11:05 AM Staff 6 (LPN Resident Care Manager Support) acknowledged risk and benefit information related to the use of Duloxetine was not provided to Resident 9.

Based on interview and record review it was determined the facility failed to assess significant weight loss for 1 of 2 sampled residents (#11) reviewed for nutrition. This placed residents at risk for additional weight loss. Findings include: Resident 11 admitted to the facility in 5/2023 with diagnoses of vascular dementia and malnutrition. A 5/2/23 Nutrition Care Plan revealed Resident 11 was at risk for impaired nutrition due to severe malnutrition and vascular dementia with a goal of Resident 11 maintaining or increasing her/his weight to above 167 pounds. The interventions for Resident 11 included a referral to a dietitian for evaluation and recommendations as needed. A 5/12/24 Dietitian Assessment revealed Resident 11 weighed 157.4 pounds and weight gain was beneficial. A 7/23/24 Provider Progress Note revealed Resident 11 weighed 164.9 pounds, her/his weight was stable for the last six months, no additional interventions were put in place. An 8/21/24 Provider Progress Note revealed Resident 11 weighed 164.8 pounds, her/his weight was stable for the last six months, no…

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 offer pneumococcal immunizations for 1 of 5 sampled residents (#27) reviewed for immunizations. This placed residents at risk for lack of vaccination. Findings Include: Resident 27 admitted to the facility in 2/2024 with diagnoses including chronic pain. Resident 27's immunization records did not indicate if she/he was assessed for, offered, or declined a pneumococcal vaccination following admission to the facility. On 10/24/24 at 12:06 PM Staff 3 (Regional RN) stated the medical record showed no documentation the facility offered a pneumococcal vaccination to Resident 27.

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 were free from physical abuse for 1 of 15 sampled residents (#2) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 2 was admitted to the facility in 1/2024 with diagnoses including dementia. Resident 2's most recent MDS assessment dated [DATE] revealed no BIMS score, which indicated she/he had severe cognitive impairment. Resident 2 had no behavioral issues documented. Resident 1 was admitted to the facility in 3/2022 with diagnoses including dementia and delusional disorder. Resident 1's most recent MDS assessment dated [DATE] revealed a BIMS score of 9, which indicated she/he had moderate cognitive impairment. Behaviors documented were physical and verbal symptoms directed toward others which placed other residents at significant risk of physical injury. Interventions were to remove her/him from the area and provide low stimulus diversional activities. On 2/23/24 the facility…

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 and interview it was determined the facility failed to discard expired medication for 1 of 1 medication room reviewed for medication storage. This placed residents at risk for receiving ineffective medications. Findings include: On 11/22/19 at 12:26 PM the medication storage room was observed to have three unopened multi-dose bottles of Loperamide Hydrochloride suspension (medication used to treat diarrhea) with an expiration date of 10/2019 and a unopened fleet enema with an expiration date of 5/31/2019. On 11/22/19 at 12:30 PM Staff 9 (RN) confirmed three multi-dose bottles of Loperamide Hydrochloride suspension and one fleet enema were expired and were expected to be removed from the medication storage room. On 11/26/19 at 2:30 PM Staff 2 (DNS) stated her expectation was all expired medications were to be removed from the medication storage room and destroyed.

Based on observation, interview and record review it was determined the facility had a medication error rate of greater than 5%. The facility's error rate was 7.69% with two errors in 26 opportunities. This placed residents at risk for inaccurate medication dosage. Findings include: a. Resident 5's 11/2019 MAR indicated the resident received Albuterol inhaler two puffs two times a day. On 11/25/19 the Albuterol inhaler manufacturer dosing recommendations indicated to wait one minute between each inhaler puff administered. The facility's 5/2010 policy on administering medication through a metered dose inhaler indicated to allow at least one minute between inhaler puffs. On 11/25/19 at 9:00 AM Staff 10 (CMA) was observed to administer two puffs of the Albuterol metered dose inhaler to Resident 5. The two puffs of medication were observed to be administered within five seconds between each puff. On 11/25/19 at 9:30 AM Staff 10 stated she was unaware of any spacing parameters when administering a metered dose inhaler. On 11/26/19 at 1:33 PM Staff 2 (DNS) stated her expectation and…

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 proper infection control during medication administration for 1 of 6 sampled residents (#5) reviewed for medication administration. This placed residents at risk for cross-contamination and infection. Findings include: On 11/25/19 at 9:20 AM during medication administration Staff 10 (CMA) was observed to administer to Resident 5 Miralax (bowel medication), a medication dissolved in water, in a disposable plastic cup. Resident 5 was observed to drink one fourth of the dose. Staff 10 placed the used, contaminated, unlabeled plastic cup on the clean medication cart and walked away from the cart. On 11/25/19 at 9:30 AM Staff 10 stated she contaminated the medication cart and placed other residents at risk of cross-contamination by placing the used contaminated plastic cup on her clean medication cart. She acknowledged she intended to offer the medication to Resident 5 at later time. On 11/26/19 at 1:33 PM Staff 2 (DNS) confirmed contaminated items, such as used medication cups, were not to…

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.