Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Marquis Plum Ridge Post Acute Rehab during CMS and state inspections, most recent first.
A resident admitted with Medicare Part A benefits remained in the facility after Part A coverage ended, but the facility did not provide the required SNF ABN to notify the resident of potential financial liability for continued services. Staff confirmed the SNF ABN was not completed, and the Administrator acknowledged the omission.
A resident who needed assistance with ADLs and had an open wound and respiratory failure did not receive sufficient bathing after admission. The bathing log showed refusals, but there was no documented nursing follow-up or interventions, and staff interviews showed communication failures between CNAs and nursing about the refusals. The resident reported only one bath offer, no bathing for a week, and no follow-up after requesting bathing.
Failure to clarify and follow a resident’s daily weight order occurred for a resident with HF, AFib, and COPD. The TAR showed ordered daily weights, but weights were missing on multiple days while the resident had repeated weight gains, including a 10-lb increase over several days. Chart notes referenced weight warnings and monitoring, but staff reported there were no documented parameters for reporting weight changes and the DNP was not notified when the resident’s weights fell outside expected limits.
A resident with stroke-related left-sided hemiplegia and depression did not receive appropriate ROM support for the left arm and hand. The care plan included ROM for the left leg only, OT documented impaired left upper extremity ROM, and staff confirmed there was no left upper extremity ROM program in place. The resident was observed with fixed hand contractures and stated staff did not assist with stretching, while CNA care was limited to routine hand hygiene and nail care.
A resident with PTSD related to military service was not timely reassessed for trauma-informed needs after readmission, and the social services assessment did not address PTSD, triggers, or coping mechanisms. The care plan later noted depressed mood and flashbacks but missed loud noises as a trigger, even though the resident became agitated when discussing trauma and reported that noise from neighboring rooms was bothersome. Staff knew about the resident’s noise-related anxiety and complaints, but the concerns were not fully documented or incorporated into the care plan.
Food Temperatures Not Maintained During Meal Service: A resident with respiratory failure and another resident with kidney failure and DM received breakfast trays that were delayed or left on an uninsulated cart, and one resident reported food was barely warm and had to be reheated. Another resident with dialysis and DM reported an early tray was not delivered, trays were left sitting out, and reheated food became mushy and tasted awful. Staff stated early trays were prepared around 7:20 AM, the carts were not insulated, and delayed delivery made it difficult to keep food warm.
A CMA failed to follow infection control technique while preparing medication for administration through a resident’s feeding tube. The medication cup, fluids used to mix the medication, and syringe were placed on the bedside table without a clean barrier, and the Administrator and DNS acknowledged the lapse.
The facility failed to label opened OTC medications on three medication carts, as observed by surveyors. Multiple bottles were found without open date labels, which was acknowledged by a CMA and the DNS, who stated that all medications should be labeled and dated when opened.
The facility failed to maintain proper food temperatures, leading to resident complaints about cold and unpalatable meals. The Dietary Manager and Administrator were aware of these issues, which were confirmed during a resident council meeting and test tray sampling. Multiple residents, including those with medical conditions like diabetes and surgical aftercare, reported receiving cold meals, such as beef stroganoff and breakfast burritos.
A facility failed to provide quarterly Personal Incidental Funds (PIF) statements to the designated representative of a resident with severe cognitive impairment. The resident's family member, who held power of attorney, did not receive any PIF statements, as confirmed by both the family member and the facility's office manager.
The facility failed to assist three residents in formulating advance directives, potentially leading to healthcare decisions that conflict with their wishes. Despite being cognitively intact, these residents were not offered advance directives, and the facility was behind on quarterly Interdisciplinary Care Conferences, contributing to the oversight.
A resident's bank card was misused by a former Activity Assistant, leading to unauthorized ATM withdrawals totaling $3,320. The staff member claimed coercion by an individual she believed to be a family member of the resident. The facility identified the suspect with law enforcement assistance and reimbursed the family.
A resident with PTSD reported feeling verbally abused after being forced to take a shower, contrary to their care plan preferences. The facility's investigation was inadequate, lacking witness statements and a resident interview. Staff involved claimed the resident did not express refusal or distress during the incident, but the resident later reported feeling verbally abused. The administrator acknowledged the investigation's shortcomings.
The facility failed to conduct quarterly care conferences for three residents, leading to a deficiency in care planning. A resident admitted with weakness did not have any quarterly care conferences after March 2024, and another resident with surgical aftercare needs did not have conferences after September 2024. The absence of these conferences was confirmed by both the residents and the facility administrator.
The facility failed to accurately assess and document pressure ulcers for two residents, leading to potential risks of worsening wounds. One resident's Stage 4 ulcer was misclassified due to slough, while another resident's heel ulcer care plan was not followed, with staff unaware of the wound and necessary offloading measures. The DNS and administrator acknowledged these deficiencies.
Failure to Provide SNF ABN After Medicare Part A Coverage Ended
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) to 1 of 3 sampled residents reviewed for beneficiary notification. Resident 13 was admitted in 12/2025 with Medicare Part A benefits, and the facility’s SNF Beneficiary Notification Review form showed the resident’s last covered day for Medicare Part A services was 2/18/26 while the resident remained in the facility. Despite the termination of Part A coverage and the resident’s continued stay, the resident was not given a SNF ABN to notify them of potential financial liability for services received. Staff 19 confirmed that residents whose Part A services end and who remain in the facility should receive a SNF ABN in addition to a Notice of Medicare Non-Coverage, and stated that the SNF ABN was not completed for Resident 13. Staff 1 acknowledged the facility failed to complete the required SNF ABN for Resident 13.
Failure to Provide and Follow Up on Bathing Refusals
Penalty
Summary
The facility failed to ensure sufficient bathing was provided to a dependent resident who required assistance with activities of daily living. The resident was admitted with diagnoses including an open wound of the left buttock and respiratory failure with hypoxia, had a BIMS score of 15, and was identified in the care plan as needing one staff member for physical assistance, with staff to keep clothing clean and appropriate and to account for anxiety related to confined spaces. The multidisciplinary care conference also noted the resident required supervised assistance for safety and moderate assistance with ADLs, including personal care tasks. The bathing task log showed the resident declined bathing on two occasions, but the clinical record contained no documentation of follow-up or interventions related to those refusals. The resident stated only one bed bath had been offered since admission, that a shower could not be received because of the wound, that no bathing occurred for one week, and that requests for bathing were not followed up. Staff interviews confirmed communication breakdowns around the refusals, with the CNA stating the refusal was communicated to nursing, while the LPN and RN stated they were not notified and expected to be informed so they could address the refusal directly and document it. The resident care manager acknowledged the resident did not receive a shower for one week after admission and that improved communication and interventions were necessary.
Failure to Clarify and Follow Daily Weight Orders
Penalty
Summary
The facility failed to clarify and follow physician orders for daily weights for a resident admitted with heart failure, atrial fibrillation, and COPD. The resident’s TAR showed an order for daily weights every day shift, but weights were not documented on multiple days in April and May 2026, including several dates when the resident had weight increases of more than two pounds. The record also showed a 10-pound gain over a five-day period in May 2026, with no daily weights documented on several intervening days. The resident’s chart included a signed Medication Review Report showing the daily weight order was active, verbally prescribed, and started in August 2024. Notes in May 2026 referenced weight warnings and monitoring for trending weights, but no additional documentation was found in the clinical record. Staff interviews indicated CNA staff obtained the weights, but there were no documented parameters for reporting weight changes and no weights were reported to the DNP. Other staff stated nursing staff were expected to clarify the order and assess weight fluctuations, but could not identify specific weight parameters, and the DNP stated there was an understanding that residents with heart failure should have daily weights according to her specified parameters, yet she was not notified when the resident’s weights fell outside those parameters.
Failure to Provide Left Upper Extremity ROM Support
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent further decrease in range of motion for a resident admitted with diagnoses including cerebral infarction, left-sided hemiplegia/hemiparesis, and depression. The resident’s care plan included restorative nursing range of motion exercises for the left leg, but it did not include interventions for the left arm or hand. The most recent OT evaluation documented impaired left upper extremity range of motion in the shoulder, elbow, wrist, fingers, and thumb, and also stated the resident once had an RA program for left upper extremity range of motion. The OT discharge summary did not reflect that a left upper extremity range of motion program had been established prior to discharge. During observation and interview, the resident stated staff did not assist with range of motion of the left arm and hand and that the resident tried to do stretching independently using a foam pool noodle, which could not be located on one date. The resident’s left hand was observed with contractures of all fingers and fixed in a cupped position. The resident later stated a washcloth was being used in the left hand instead. CNA staff stated they provided no special care for the resident’s left hand or wrist, and another CNA said care was limited to routine hand hygiene and nail care. The Director of Rehabilitation confirmed there was no range of motion program in place for the left upper extremity, and the DNS stated the posted splint information in the resident’s room was outdated and the splint had been discontinued a long time ago.
Failure to Assess PTSD Triggers and Provide Trauma-Informed Care
Penalty
Summary
The facility failed to ensure a resident with PTSD received timely assessment and trauma-informed care after readmission. The resident had diagnoses including heart failure and PTSD, with a prior social services assessment noting PTSD related to military service and coping mechanisms that included trying not to think about it and attending a PTSD support group. No revised assessment related to the resident’s PTSD was found in the clinical record after the earlier admission, and upon readmission the social services assessment did not address PTSD, triggers, or coping mechanisms. The quarterly MDS showed the resident was cognitively intact with a BIMS score of 15. The revised care plan later identified a sad or depressed mood related to PTSD and possible flashbacks of violent wartime events, and noted attendance at a veteran support group with family transportation, but it did not identify loud noises as a trigger. During observation, the resident became agitated when asked about trauma triggers and stated that loud noises and noises from the neighboring room bothered the resident. Staff interviews showed multiple staff were aware of the resident’s noise-related anxiety and complaints, but the concerns were not documented as behaviors, the resident was not recently interviewed about PTSD needs on readmission, and the updated care plan was based on an outdated social services assessment. Staff also acknowledged newly identified triggers were not incorporated into the care plan and that the resident’s repeated complaints about noise were signs of agitation that should have been documented.
Food Temperatures Not Maintained During Meal Service
Penalty
Summary
The facility failed to ensure food temperatures were maintained during meal service for 3 of 13 sampled residents reviewed for dining observations, involving residents 26, 52, and 70. Resident 26, admitted with diagnoses including compression fracture of the spine and respiratory failure, had a BIMS score of 14 and was observed eating breakfast in the room with fried eggs and toast that the resident said were barely warm; staff then removed the plate to reheat the eggs and toast in a microwave. Resident 70, admitted with kidney failure and diabetes and assessed with a BIMS score of 15, was identified as needing early breakfast trays daily, and an open uninsulated cart with covered trays was observed unattended in the hallway before the trays were delivered later by staff. Resident 70 stated the food was cold 50% of the time and that trays were often left undelivered outside the room for an extended period. Resident 52, admitted with dialysis and diabetes, was supposed to receive an early breakfast due to dialysis and being an early riser, but stated the tray was not delivered early and was left sitting on the meal cart; the resident also reported that reheated food became mushy and tasted awful. Staff stated early trays were completed around 7:20 AM, that the meal carts were not insulated, and that delayed delivery made it difficult to maintain food temperatures. Staff also stated one resident's tray was left in the kitchenette on the counter because there was no room in the refrigerator and would be reheated later when the resident returned.
Infection Control Lapse During Feeding Tube Medication Administration
Penalty
Summary
The facility failed to follow proper infection control techniques during medication administration via a feeding tube for one resident who was admitted in 5/2025 with diagnoses including quadriplegia and required a feeding tube for medication administration. On 5/20/26 at 4:39 PM, a CMA was observed preparing medication to administer through the resident’s feeding tube without placing a clean barrier on the bedside table before setting down the medication cup, fluids used to mix the medication, and a syringe used for administration. At 5:00 PM, the CMA acknowledged that she did not place a clean barrier on the bedside table before placing the medication, fluids, and syringe there. At 5:14 PM, the Administrator and DNS acknowledged that the clean barrier should have been placed on the bedside table before those items were set down for feeding tube medication administration.
Failure to Label Opened OTC Medications
Penalty
Summary
The facility failed to ensure proper labeling of biologicals on three out of six medication carts, which was observed during a survey. On January 29, 2025, at 10:59 AM, multiple bottles of over-the-counter (OTC) medications were found opened without open date labels on the front hall medication cart. Additionally, two other medication carts located on the front and back halls were observed to have multiple bottles of OTC medications also lacking open date labels. Staff 17, a Certified Medication Aide (CMA), acknowledged the presence of these unlabeled medications across all three carts. Later, at 11:59 AM, Staff 2, the Director of Nursing Services (DNS), confirmed the observations and acknowledged the issue of multiple OTC medications without open date labels on the bottles. Staff 2 stated that her expectation was for staff to label and date every medication upon opening.
Facility Fails to Maintain Proper Food Temperatures
Penalty
Summary
The facility failed to maintain proper food temperatures for meals served to residents, as observed during a survey. The Dietary Manager and Administrator were aware of ongoing complaints from residents about cold and unpalatable food. During a resident council meeting, nine residents expressed concerns about meals being served cold. A test tray sampled by the survey team revealed that the beef stroganoff was barely warm, noodles were dried out, green beans were cold, and other items like grilled cheese and tater tots were not served at appropriate temperatures. Multiple residents, including those with specific medical conditions such as pressure ulcers, diabetes, and surgical aftercare, reported receiving cold meals. Resident 3, for instance, experienced cold and undercooked food during dinner and lunch observations. Resident 6, who has diabetes, also reported consistently receiving cold meals, including a breakfast burrito. Resident 37, admitted for surgical aftercare, similarly reported cold meals, including a hamburger and beef stroganoff. Resident 23, with a diagnosis of diabetes, and Resident 266, with a hip fracture and depression, also reported receiving cold meals. Resident 23 described the grilled cheese as hard and the beef stroganoff as having a mechanical soft texture that was unpleasant. Resident 266, who is cognitively intact, noted that meals were often cold, including the stroganoff and green beans. The Administrator acknowledged the complaints and stated that food should be served at the appropriate temperature and palatability for all residents.
Failure to Provide Quarterly PIF Statements to Resident's Representative
Penalty
Summary
The facility failed to provide quarterly statements of Personal Incidental Funds (PIF) to the designated representative of a resident with severe cognitive impairment. The resident, admitted in 2013 with diagnoses including a stroke and depression, had a BIMS score of 3, indicating severe cognitive impairment. The resident's family member, who was the designated power of attorney, did not receive any quarterly PIF statements from the facility. This was confirmed during an interview with the family member and the facility's office manager, who acknowledged that the statements should have been generated and sent but were not.
Failure to Assist Residents with Advance Directives
Penalty
Summary
The facility failed to assist residents in formulating advance directives for three of the four sampled residents, which could lead to healthcare decisions conflicting with the residents' wishes. Resident 3, admitted in March 2023 with a diagnosis of weakness, was found to be cognitively intact according to the Annual MDS conducted in March 2024. However, during an Interdisciplinary Care Conference in March 2024, it was noted that Resident 3 did not have an advance directive. The resident expressed on January 27, 2025, that staff had not offered an advance directive and wished to have options reviewed. Staff 26, the Social Service Director, acknowledged the need to review advance directive options during quarterly Interdisciplinary Care Conferences, but Staff 1, the Administrator, admitted that these conferences were behind schedule, and advance directives were not being followed up on. Similarly, Resident 7, admitted in August 2023 with respiratory failure, was also cognitively intact as per the Annual MDS in August 2024. The Interdisciplinary Care Conference in February 2024 revealed the absence of an advance directive for this resident. On January 27, 2025, Resident 7 stated that staff had not offered an advance directive and wanted options reviewed. Resident 37, admitted in February 2023 for surgical aftercare, was cognitively intact according to the Annual MDS in February 2024. The Interdisciplinary Care Conference in September 2024 also showed no advance directive for this resident, who expressed a desire for one on January 28, 2025. The facility's failure to keep up with quarterly Interdisciplinary Care Conferences contributed to the lack of follow-up on advance directives for these residents.
Misappropriation of Resident's Funds by Staff Member
Penalty
Summary
The facility failed to protect a resident from the misappropriation of property, specifically involving the wrongful use of the resident's bank card. The incident involved a resident who was admitted in April 2022 with a diagnosis of cirrhosis of the liver. A public complaint was received alleging that the resident had money stolen from their bank account. An investigation revealed that the resident's bank card was used for unauthorized ATM withdrawals totaling $3,320 over a period of three days. The facility's Business Office Manager was notified of a declined payment, which led to the discovery of the missing funds. Further investigation identified a former Activity Assistant as a suspect, who was later arrested. The staff member claimed to have been coerced by an individual she believed to be a family member of the resident, who threatened her and her family. She admitted to assisting this individual in withdrawing money from an ATM, although she claimed she was unaware it was the resident's account. The facility assisted law enforcement in identifying the suspect and reimbursed the family for the stolen amount.
Inadequate Investigation of Verbal Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an alleged incident of verbal abuse involving a resident with PTSD. The resident, admitted in August 2023 with a diagnosis of respiratory failure, reported feeling verbally abused after being forced to take a shower by a staff member. The resident expressed that being told what to do was a trigger for their PTSD. Despite the resident's care plan indicating a preference for bed baths and that they would request a shower if desired, the staff proceeded with the shower, leading to the resident's distress. The investigation into the incident was inadequate, as it lacked witness statements and did not include an interview with the resident regarding the abuse allegation. Staff involved in the incident reported that the resident did not express refusal or feelings of abuse during the shower. However, the resident later communicated to another staff member that they felt verbally abused and had expressed a desire not to shower. The facility's administrator acknowledged that the investigation was not thorough, as it did not meet the expectations of interviewing the resident and obtaining written and signed witness statements.
Failure to Conduct Quarterly Care Conferences
Penalty
Summary
The facility failed to conduct quarterly care conferences as required for three residents, leading to a deficiency in care planning. Resident 3, admitted in March 2023 with a diagnosis of weakness, did not have any quarterly care conferences after March 2024. This was confirmed by the resident, who expressed concerns about not having had a care conference in months. The facility administrator also confirmed the lack of quarterly care conferences for this resident. Similarly, Resident 7, also admitted in March 2023 with a diagnosis of weakness, did not receive quarterly care conferences after February 2024. The resident expressed similar concerns about the absence of care conferences. Resident 37, admitted in February 2023 for surgical aftercare, did not have quarterly care conferences after September 2024. This lack of regular care conferences was confirmed by both the residents and the facility administrator, indicating a systemic issue in the facility's care planning process.
Failure to Accurately Assess and Follow Care Plans for Pressure Ulcers
Penalty
Summary
The facility failed to accurately assess and document the pressure ulcer status of two residents, leading to potential risks of inaccurate assessment and worsening of wounds. Resident 3 was admitted with a Stage 4 pressure ulcer, but the Wound Evaluation Form inaccurately documented the wound as a Stage 4 when it was actually unstageable due to the presence of slough. This discrepancy was acknowledged by the Director of Nursing Services (DNS), indicating a failure in proper wound assessment and documentation. Resident 31, who was cognitively intact, had a pressure injury on the right heel that required offloading with a pillow or heel boot protector as per the care plan. However, observations revealed that the resident's heel was not offloaded, and several staff members, including CNAs and an LPN, were unaware of the wound and the necessary care plan. The RN Case Manager confirmed the staff's failure to follow the care plan, and the facility's administrator and DNS acknowledged the oversight, highlighting a lack of communication and adherence to care protocols.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
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