Marquis Autumn Hills Memory Care

In the surveyor’s words

From the most serious findings on record at Marquis Autumn Hills Memory Care, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 15, 2021

  Based on observation, interview and record review it was determined the facility failed to evaluate the effectiveness of current interventions and revise as necessary, to provide appropriate supervision to prevent elopement for 1 of 3 sampled residents (Resident 1). This placed residents at risk for serious injury or harm. This failure, determined to be an immediate jeopardy situation, resulted in Resident 1's elopement from the locked memory care unit and the facility's secured courtyard on multiple occasions. Resident 1 also experience a non serious closed head injury following an episode of elopement from the secured courtyard. […]

• Actual harm, isolatedF684Apr 10, 2024

  Based on interview and record review it was determined the facility failed to act upon complaints of hip pain and rule out significant injury after multiple falls for 1 of 3 sampled residents (#3) reviewed for falls. As a result, Resident 3 experienced prolonged pain over a period of four weeks, and a delay in diagnosis of hip fracture requiring hospitalization and surgery. The hip fracture was not diagnosed until 8/5/23, 31 days after her/his fall on 7/4/23. Findings include: Resident 3 was admitted to the facility in 3/2023, with diagnoses including stroke and dementia. Resident 3's care plan dated 2/28/23 noted she/he was was a fall risk due to impaired mobility, gait unsteadiness and decreased safety awareness due to her/his cognitive impairment. […]

• No harm, potential for more than minimal, patternF919Feb 27, 2026

  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. […]

• No harm, potential for more than minimal, patternF761Oct 24, 2024

  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 ,d+[DATE], 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. […]

• No harm, potential for more than minimal, patternF880Oct 24, 2024

  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. […]