Marquis Plum Ridge Post Acute Rehab

In the surveyor’s words

From the most serious findings on record at Marquis Plum Ridge Post Acute Rehab, in the surveyor’s own words.

• Actual harm, isolatedF600Jul 9, 2021

  Based on interview and record review, it was determined the facility failed to ensure residents were free from neglect. The facility failed to ensure staff did not provide care alone when two-person assistance was required for 3 of 4 sampled (#s 3, 5 and 11)residents reviewed for accidents. Resident 11 experienced a fall and sustained bilateral fractures to her/his left proximal femur (the end closest to the hip bone which includes the rounded femoral head, which is part of the hip joint) and right distal femur (long bone of the thigh). Resident 11 was transferred to the hospital. […]

• Actual harm, isolatedF686Jul 9, 2021

  Based on interview and record review it was determined the facility failed to implement, follow, and maintain pressure ulcer treatments for 1 of 3 sampled residents (#4) reviewed for pressure ulcers. Resident 4's pressure ulcer deteriorated and required surgical intervention. Findings include: The 3/2018 Pressure Injuries/Skin Breakdown Clinical Protocol indicated the physician authorized pertinent orders related to wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings, and application of topical agents. Resident 4 was admitted to the facility 5/14/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/14/21 Progress Note revealed Resident 4 was alert, oriented and could verbalize her/his needs and wants. […]

• Actual harm, isolatedF689Jul 9, 2021

  Based on observation, interview and record review it was determined the facility failed to execute fall risk interventions for 4 of 4 residents (#s 3, 5, 6 and 11) reviewed for accidents. This placed residents at risk for falls. Resident 11 experienced a fall, sustained bilateral fractures and was transferred to the hospital. Findings include: 1. Resident 11 was admitted to the facility in 1/2020 with diagnoses including Alzheimer's disease. A 1/28/20 care plan indicated Resident 11 was a fall risk and her/his interventions included: bed in low position, commonly used items in reach and directed the reader to the mobility plan of care. […]

• No harm, potential for more than minimal, widespreadF812Aug 26, 2022

  Based on observation and interview it was determined the facility failed to ensure hair was restrained by staff preparing food in 1 of 1 kitchen. This placed residents at risk for contaminated foods. Finding include: On 8/24/22 at 12:10 PM Staff 19 (Cook) was observed in the kitchen working directly with food and preparing multiple containers and menu items for the evening meal. Staff 19 wore no hair restraint during food preparation. On 8/24/22 at 12:44 PM Staff 21 (Cook) stated staff were not to enter the kitchen preparation area without hair restraints. Staff 21 stated Staff 19 never wore any hair restraint when he worked in the kitchen. On 8/24/22 at 1:05 PM Staff 19 stated he was never informed a hair restraint was required during food preparation. […]

• No harm, potential for more than minimal, widespreadF880Aug 26, 2022

  Based on observation, interview and record review it was determined the facility failed to ensure staff removed gloves while meal trays were delivered and followed appropriate hand hygiene or PPE (Personal Protective Equipment) utilization for 1 of 1 kitchen and 1 of 2 dining rooms. This placed residents at risk for food borne illnesses and contracting COVID-19. Findings include: The 2/2022 CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease (COVID-19) Pandemic revealed source control for healthcare staff could include an N95 mask or well-fitting medical mask and could be used for an entire shift unless the mask become soiled, damaged, or hard to breathe through. […]