Marquis Vermont Hills

In the surveyor’s words

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

• Actual harm, isolatedF689Jul 23, 2021

  Based on interview and record review it was determined the facility failed to assess for care plan effectiveness, identify and implement new fall interventions and provide adequate supervision needed to prevent falls for 1 of 3 sampled residents (#8) reviewed for falls. This failure resulted in the resident having ten falls, two with serious injury including a head injury and fractured neck which required emergency medical services and treatment at the hospital. Findings include: Resident 8 was admitted to the facility in 7/2019 with diagnoses including [MEDICATION(S)] (mid-region of the spine) spinal compression fractures and rib fractures post fall, acute pain secondary to trauma and dementia. […]

• No harm, potential for more than minimal, widespreadF880Dec 20, 2022

  Based on observation and interview, it was determined the facility failed to process laundry in accordance with accepted national standards in order to produce hygienically clean laundry and prevent the spread of infection to the extent possible for 2 of 2 laundry washing machines reviewed for infection control. This placed residents at risk of contaminated laundry. The findings include: According to the Center for Disease Control and Prevention: Guidelines for Environmental Control in Healthcare Facilities (2003); Laundry and Bedding Section G.II.D: -Do not leave damp textiles or fabrics in machines overnight. During an observation on 12/14/22 at 1:44 PM wet laundry including linens and towels was observed in both washing machines. […]

• No harm, potential for more than minimal, patternF812Dec 19, 2024

  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. […]

• No harm, potential for more than minimal, patternF842Jan 12, 2024

  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. […]

• No harm, potential for more than minimal, isolatedF600May 22, 2026

  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… […]