Marquis Vermont Hills

Based on observation, interview and record review it was determined the facility failed to ensure residents were free from unwanted sexual contact by Witness 2 (Non-Family Visitor) for 1 of 1 sampled Resident (#12) reviewed for abuse. This placed residents at risk for unwanted sexual contact and mental anguish. Findings include: Sexual abuse is defined as nonconsensual sexual contact of any type with a resident as defined at 42 CFR S483.5. Sexual contact is considered nonconsensual if the resident either:-Appears to want the contact to occur, but lacks the cognitive ability to consent; or-Does not want the contact to occur.Resident 12 was admitted to the facility in 1/2025 with diagnoses including vascular dementia (a type of dementia caused by reduced blood flow to the brain, leading to cognitive decline).Resident 12's 3/29/26 Quarterly MDS indicated the resident had moderate cognitive impairment.Random observations from 5/18/26 through 5/22/26 between the hours of 8:00 AM through 4:00 PM revealed Resident 12 and Resident 52 shared a room. Residents 12 and Resident 52 were observed…

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 foods were labeled and stored in a way to minimize food spoilage in 1 of 1 kitchen reviewed for sanitation. This placed residents at risk for potential infections related to foodborne pathogens. Findings include: The facility's undated Storage of Frozen and Refrigerated Foods policy specified the following: -Food needs to be labeled with name of the product if removed from the original packaging. -No food should be stored past the expiration date. On 12/16/24 at 9:20 AM during the initial tour of the facility's kitchen, the following was observed in the walk-in refrigerator: A rolling rack containing trays of multiple undated salad items under large sheets of plastic cling film: -Partially-filled multi-use plastic bins of red beans, cottage cheese, diced hard-boiled eggs, carrots, shredded cheese; -Multi-use plastic bins of full of chopped beets, chopped bacon, garbanzo beans; -Two nearly empty multi-use plastic bins of salad dressings; and -A large multi-use plastic bin of chopped…

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 the facility failed to revise the plan of care to reflect residents' needs for 1 of 1 sampled resident (#29) reviewed for hospice. This placed residents at risk for unmet care needs. Findings include: Resident 29 was admitted to the facility in 9/2023 with diagnoses of dementia and hip fracture. Resident 29's 10/15/24 Quarterly MDS indicated he/she required partial to moderate assistance with eating. Resident 29's 10/15/24 Care Plan indicated he/she required one-on-one supervision, set up, and eating assistance for all meals. Multiple random observations from 12/17/24 through 12/18/24 revealed: -12/17/24 at 10:21 AM Resident 29 was observed sitting upright in bed with a cup of ice cream placed directly in front of him/her on an overbed table without supervision. -12/17/24 at 12:28 PM Resident 29 was observed sitting upright in bed with a lunch tray placed directly in front of him/her on an overbed table without supervision during mealtimes. -12/18/24 at 8:27 AM Resident 29 was observed sitting upright in bed with a breakfast tray…

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 obtain a physician order for a respiratory device and ensure resident respiratory equipment was maintained for 1 of 1 sampled resident (#14) reviewed for respiratory care. This placed residents at risk for increased respiratory concerns. Findings include: Resident 14 was admitted to the facility in 12/2024 with diagnoses including Alzheimer's disease and obstructive sleep apnea. The Annual MDS dated [DATE] indicated Resident 14 did not utilize a CPAP (continuous positive airway pressure) machine . A review of physician orders from 12/2024 revealed Resident 14 had no orders for use of a CPAP machine. A review of Resident 14's Care Plan and TAR from 12/2024 revealed no instructions for maintenance of the CPAP machine. On 12/17/24 at 10:41 AM Staff 5 (LPN) indicated Resident 14 used her/his CPAP machine at night. Staff 5 stated Resident 14 used her/his CPAP machine since her/his admission date and Staff 5 had cleaned it with distilled…

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 the garbage area dumpsters were covered and free from debris for 1 of 1 facility dumpster reviewed for sanitation. This placed residents at risk for exposure to used medical supplies. Findings include: The facility's undated Food/Waste Disposal policy specified the following: -Dumpster lids are to be closed at all times. -Dumpster and dumpsite area is to be kept clean and free of debris. On 12/16/24 at 9:39 AM the garbage dumpster located adjacent to the kitchen's side doorway (below the facility's E hall) was observed to be open with used examination gloves, sweetener packets, paper towels, and plastic spoons scattered on the ground at the base. A CNA stood on the railed walkway above the dumpster and threw a clear plastic bag over the railing into the dumpster. Staff 7 (Dietary Manager) stated the lid was always open to allow CNAs to throw waste into the dumpster from the end of the E hallway above. She stated this was the reason for the garbage on the ground and she cleaned it every…

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 records were accurate for 4 of 4 sampled residents (#s 8, 18, 25 and 26) reviewed for Advance Directives. This placed residents at risk for inaccurate medical interventions. Findings include: 1. Resident 8 was admitted to the facility in 9/2023 with diagnoses including Parkinson's disease. A 12/19/23 Multidisciplinary Care Conference report documented Resident 8 had an Advance Directive and a copy was in the clinical records. On 1/9/23 at 1:26 PM Staff 12 (Social Services Director) confirmed Resident 8 was documented as having a copy of an Advance Directive on file with the facility, but Resident 8 did not have an Advance Directive on file at the facility. On 1/9/23 at 2:33 PM Resident 8 stated she/he did not have an Advance Directive and did not provide an Advance Directive to the facility. 2. Resident 18 was admitted to the facility in 2/2020 with diagnoses including kidney failure. A 12/29/23 Multidisciplinary Care Conference report documented Resident 18 had an Advance Directive and a copy 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 interview and record review it was determined the facility failed to provide SNF ABN (Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage) information for 1 of 3 sampled residents (#28) reviewed for beneficiary notification. This placed residents at risk for unknown financial liabilities. Findings include: Resident 28 was admitted to the facility in 10/2023 with diagnoses including a fractured sacrum (back portion of the pelvis). A 12/12/23 NOMNC (Notice of Medicare Non-Coverage) indicated Resident 28's skilled days ended on 12/20/23. Review of Resident 28's health record indicated the resident remained in the facility and paid for her/his care with private funds. There was no documentation indicating Advance Beneficiary Notification information was provided to the resident so she/he understood what her/his daily out-of-pocket costs were. On 1/9/24 at 1:12 PM Staff 1 (Administrator) confirmed the facility failed to provide Advanced Beneficiary Notice information to Resident 28.

Based on interview and record review it was determined the facility failed to ensure dependent residents received showers for 1 of 4 sampled residents (#13) reviewed for ADLs. This placed residents at risk for unmet ADL needs and loss of dignity. Findings include: Resident 13 was admitted to the facility in 12/2023 with diagnoses including multiple sclerosis (a progressive neurological disorder). Resident 13's 12/5/23 Bathing Care Plan indicated Resident 13 required assistance from one staff for bathing. Resident 13 preferred showers on scheduled bathing days. The facility's 1/11/24 shower schedule revealed Resident 13 received showers twice a week on Sundays and Thursdays. Resident 13's 12/14/23 through 1/7/24 bathing task logs indicated the resident received a bed bath or shower on the following days: - 12/14, 12/17, 12/25 and 1/7. A review of Resident 13's Progress Notes from 12/14/23 through 1/7/24 revealed no documentation Resident 13 was provided with additional bathing opportunities when bathing was not provided. On 1/8/24 at 11:48 AM Witness 4 (Family) reported Resident 13…

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 and sufficient supervision and ensure interventions were followed to reduce the risk of accidents for 1 of 4 sampled residents (#14) reviewed for nutrition. This placed residents at risk for choking and aspiration. Findings include: Resident 14 was admitted to the facility in 12/2023 with diagnoses including stroke. Resident 14's 12/14/23 Physician Orders directed the following precautions related to the prevention of aspiration: -Provide oral care before eating or drinking, clearing secretions from the oral cavity and moistening the mouth. -Upright positioning as close as possible to a 90-degree angle. -No straws. Resident 14's 12/20/23 admission MDS revealed the resident experienced short and long term memory loss, experienced some difficulty in decision making when faced with new tasks or situations and required partial/moderate assistance with eating. The MDS also indicated the resident held food in her/his mouth/cheeks or residual food was present in her/his mouth…

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 conduct timely post-dialysis assessments for 1 of 1 sampled resident (#9) reviewed for dialysis. This placed residents at risk for unidentified complications of dialysis treatment. Findings include: Resident 9 was admitted to the facility in 12/2023 with diagnoses including diabetes and end stage kidney disease with dependence on dialysis (procedure to remove waste products from the blood). Resident 9's 12/5/23 Dialysis Care Plan indicated the resident received dialysis three times per week, had an AV fistula (a procedure that connects an artery to a vein for dialysis) in her/his left upper extremity and post-dialysis assessments were completed in order to monitor the fistula for any bleeding or swelling. On 1/10/24 at 11:54 AM Resident 9 was observed being escorted by a CNA to her/his room upon returning from dialysis. Continuous observations on 1/10/24 between 11:54 AM and 12:58 PM revealed nursing staff did not complete a post-dialysis assessment of Resident 9 upon her/his return from…

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 residents were seen by a physician at least once every 60 days for 1 of 5 sampled residents (#15) reviewed for medications. This placed residents at risk for unassessed and unmet needs. Findings include: Resident 15 was admitted to the facility in 4/2021 with diagnoses including Parkinson's disease. Review of Resident 15's 2023 health record revealed the resident's physician visits occurred on 5/6/23 and 10/10/23. On 1/11/24 at 10:27 AM Staff 5 (RNCM) stated she was aware physician visits were required at least once every 60 days. Staff 5 reviewed Resident 15's health record and confirmed the physician visits occurred only twice in 2023. On 1/11/24 at 1:08 PM Staff 2 (DNS) was notified of the findings of this investigation, acknowledged she was aware of the resident's situation and did not provide evidence to indicate Resident 15 was seen by the physician every 60 days. the facility proactively addressed the lack of physician visits.

Based on interview and record review it was determined the facility failed to provide physical therapy services as ordered for 1 of 1 sampled resident (#13) reviewed for rehabilitation services. This placed residents at risk for reduced mobility and quality of life. Findings include: Resident 13 was admitted to the facility in 12/2023 with diagnoses including multiple sclerosis (a progressive neurological disorder). Resident 13's 12/5/23 Physician Order indicated the resident was to be evaluated and treated by PT. Resident 13's 12/5/23 Physical Therapy Evaluation and Plan of Care indicated the resident was to receive PT treatment five times a week from 12/6/23 through 3/13/24. Resident 13's PT Service Log Matrix from 12/17/23 through 12/31/23 indicated the resident received six of ten treatment sessions. On 1/8/24 at 12:24 PM Witness 4 (Family) stated the week before, during and after Christmas, Resident 13 did not receive physical therapy services at the frequency ordered because the rehabilitation department was short staffed. Witness 4 stated Resident 13 laid in her/his bed for…

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 appropriate disinfection of a shared glucometer (a device used to obtain blood sugar levels) for 3 of 5 sampled residents (#s 9, 25 and 196) observed for CBG monitoring. This placed residents at risk for the spread of bloodborne infection. Findings include: The CDC website, section titled Infection Prevention during Blood Glucose Monitoring and Insulin Administration specified there was an increased risk for exposure to bloodborne viruses through contaminated equipment, such as glucometers, when shared. Using a [glucometer] for more than one person without cleaning and disinfecting it in between uses contributed to transmission of HBV (Hepatitis B virus). [Glucometers] should be cleaned and disinfected after every use. The facility's 8/2016 Obtaining a Fingerstick Glucose Level Policy & Procedure specified the following steps in the procedure: - place the equipment on the over-bed table upon a clean/protective surface; - ensure the glucometer has been disinfected before use; - obtain a…

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.