Marquis Mill Park

In the surveyor’s words

From the most serious findings on record at Marquis Mill Park, in the surveyor’s own words.

• Immediate jeopardy, patternF880Feb 3, 2025

  Based on observation, interview and record review it was determined the facility failed to follow appropriate infection control practices during a COVID-19 outbreak for 2 of 4 halls reviewed for infection control. This deficient practice was determined to be an immediate jeopardy situation and placed residents at risk for contracting COVID-19. Findings include: The CDC's 3/6/24 Preventing Transmission of Viral Respiratory Pathogens in Healthcare Settings website, https://www.cdc.gov/infection-control/hcp/viral-respiratory-prevention/index.html, specified health care personnel are advised to apply appropriate Transmission-Based Precautions when providing care to a patient with known or suspected respiratory infection. […]

• Actual harm, isolatedF760Apr 24, 2026

  Based on observation, interview and record review it was determined the facility failed to administer the correct medications for 1 of 3 sampled residents (#45) reviewed for hospitalizations. This failure resulted in Resident 45 experiencing decreased blood pressure and hospitalization. Findings include: The facility's Administering Medications policy revised 12/2025 included the following:- Medications shall be administered in a safe and timely manner, and as prescribed.- Medications must be administered in accordance with the orders.- The individual administering medications must verify the resident's identity before giving the resident her/his medications.- The individual administering the medication must check the label three times to verify the right medication, right dosage, right… […]

• No harm, potential for more than minimal, patternF761Apr 24, 2026

  Based on observation and interview it was determined the facility failed to ensure medication and treatment carts were locked and secured appropriately for 1 of 4 halls observed (200 Hall) during random observations for medication and treatment cart storage. This placed residents at risk for unsafe access to stored medications. Findings include:The facility's Security of Medication Cart policy dated 5/2010 included the following:- The nurse must secure the medication cart during the medication pass to prevent unauthorized entry.- The cart must be locked before the nurse enters the resident's room.- Medication carts must be securely locked at all times when out of the nurse's view.On 4/20/26 at 2:40 PM, Staff 17 (RN) was observed alone standing next to an unlocked medication cart in the 200… […]

• No harm, potential for more than minimal, patternF880Apr 24, 2026

  Based on observation, interview, and record review it was determined the facility failed to ensure hand hygiene was performed during wound care for 1 of 1 sampled resident (#7) reviewed for pressure ulcer. This placed residents at risk for cross contamination. Findings include: Resident 7 was admitted to the facility in 3/2026 with a diagnosis of diabetes. The facilities Standard Precautions policy and procedure last revised 5/2010 revealed hand hygiene (washing hands with soap and water or an alcohol-based hand rub), was to be performed when hands were not visibly soiled and gloves were to be changed, as necessary, during care of a resident to prevent cross-contamination when moving from a dirty site to a clean site. […]

• No harm, potential for more than minimal, patternF880Aug 25, 2023

  1. Based on observation, interview and record review it was determined the facility failed to ensure adequate hand hygiene during medication administration for 3 of 9 sampled residents (#s 33, 41 and 161) reviewed during medication administration. This placed residents at risk for spread of infection. Findings include: The facility's 5/2020 Handwashing/Hand Hygiene Policy & Procedure specified hand hygiene was the primary means to prevent the spread of infection. Employees must perform hand hygiene before and after direct contact with a resident or their immediate environment. On 8/24/23 at 2:26 PM Staff 3 (LPN) dispensed and administered Resident 41's medication in the resident's room. Staff 3 did not perform hand hygiene before or after she dispensed and administered the medication. […]