Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Marquis Plaza Regency Post Acute Rehab during CMS and state inspections, most recent first.
A resident with a history of dementia, CVA, prior ICH, multiple falls, and impaired mobility experienced an unwitnessed fall while alone in a dark room after attempting to ambulate without required assistance. Staff found the resident on the floor with the call light on but did not initiate an SBAR or neuro assessment, despite facility policy requiring neuro checks after unwitnessed falls and changes in condition. Over the next day, the resident developed increasing confusion, lethargy, poor oral intake, and inability to hold a conversation. The NP changed pain medication but did not order a STAT CT or immediate transfer, instead planning delayed lab work, and no formal neuro assessment protocol was started or documented. The resident was eventually sent to the hospital at family request, where imaging showed a left subdural hematoma and subarachnoid hemorrhage, confirming a serious head injury that had not been promptly identified or evaluated in the facility.
A resident with cognitive impairment sustained a skin tear during an episode of agitation and combative behavior while being transferred to a wheelchair. Although a Physician's Assistant was notified and a dressing was applied, there was no documented evidence that the resident's representative was informed of the incident or injury, despite facility policy requiring such notification.
The facility failed to develop comprehensive care plans for several residents, leading to deficiencies in addressing their medical needs. A resident with constipation due to pain medication lacked a care plan for bowel management. Another resident receiving treatment for insomnia and edema did not have corresponding care plans. Additionally, a resident with PTSD did not have a care plan addressing their condition, despite exhibiting related behaviors. These oversights were confirmed by facility staff, highlighting a failure to adhere to care planning policies.
A resident was discharged without a complete discharge summary, lacking a recapitulation of their stay, treatments, and a physician's signature. The facility used the wrong template, and the resident and family did not receive necessary documentation, potentially affecting post-discharge care.
A resident with a pressure injury on the right knee did not receive wound care according to physician orders. The wound care nurse used silver alginate without a physician's order, contrary to the facility's policy requiring verification of orders before treatment. This oversight was confirmed by the DNS and had the potential to delay wound healing.
A resident with end-stage renal disease had blood pressures taken on their left arm, where a fistula was located, despite a care plan and physician's order prohibiting it. This oversight was confirmed by staff and led to complications with the resident's dialysis access, requiring surgical intervention.
A resident with cerebrovascular disease and hypertension received seven medications late, resulting in a medication error rate of 25.93%. The medications were administered beyond the allowed timeframe, contrary to the facility's policy. The LPN and DON confirmed the late administration did not adhere to the policy, which requires timely medication administration.
A resident with multiple health conditions was not screened for pneumococcal vaccine eligibility, nor provided with education or the opportunity to receive the vaccine, as required by the facility's policy. The Infection Preventionist confirmed the lack of documentation and adherence to the vaccination protocol.
Failure to Perform Neuro Checks and Timely Evaluation After Unwitnessed Fall Resulting in Head Bleed
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and appropriate post-fall assessment for a resident at high risk for falls following an unwitnessed fall. The resident had a history of dementia, CVA, intracerebral hemorrhage, osteoarthritis, CHF, hypertension, diabetes, bilateral knee replacement, and multiple prior falls, including a fall with fracture within the six months prior to admission. On admission, the resident was care planned as at risk for falls due to decreased mobility from infected knee hardware, pain requiring narcotics, and a history of falls, and required assistance with positioning, transfers, and ambulation. Prior to the fall, nursing documentation described the resident’s baseline mentation as alert and oriented to person, place, and time, pleasant, cooperative, and without neurological concerns. On the date of the incident, a night-shift RN found the resident on the floor in their room at approximately 6:05 AM after an unwitnessed fall. The room was dark, the door was closed, the call-light indicator was on, and the call-light button was on the floor. The resident was lying on their back, slightly to the side, with their head near the dresser, and it was believed the resident had attempted to ambulate to the bathroom without assistance despite requiring assistance for transfers and ambulation. A fall/post-fall assessment was completed, and the NP and family were notified. The resident denied hitting their head, and no SBAR or neurological assessment was initiated at that time, despite facility protocol requiring neuro assessments after an unwitnessed fall and the resident’s known fall risk and mobility limitations. Following the fall, the resident developed increasing confusion, lethargy, and poor oral intake. An SBAR later documented that after receiving Oxycodone 10 mg, the resident became confused and disoriented, with continued confusion later that evening; the physician was notified, Oxycodone was discontinued, and Tramadol was ordered. Nursing notes documented that overnight the resident continued to exhibit delirium and confusion. The next day, the resident was described as confused, lethargic, forgetful, with decreased awareness of surroundings and refusal to eat, and later as alert but disoriented, lethargic, non-responsive at times, unable to hold a conversation, exhibiting hallucination-like behaviors, with poor oral intake and decreased participation in therapy. The NP evaluated the resident, attributed confusion to multiple factors including diagnoses and medications, did not order a STAT CT scan, and instead ordered labs for a later date, with no immediate imaging or transfer planned. Despite facility policy requiring neurological assessments following a fall involving head trauma or a change in condition, the RCM, ADON, and NP confirmed that no neurological assessment protocol was initiated or documented after the unwitnessed fall, even as the resident’s confusion and lethargy progressed. The resident was ultimately transferred to the hospital at the family’s request due to worsening condition, including ongoing confusion, lethargy, inability to hold a conversation, and decreased oral intake. Emergency Department records documented that the resident presented after an unwitnessed fall with subsequent confusion and altered mental status, with sudden worsening of mental status and bruising to the left cheek concerning for head strike. A CT scan of the head revealed a 4 mm left subdural hematoma and a posterior left temporal subarachnoid hemorrhage with no significant mass effect. Prior imaging from before admission had shown only a chronic infarct with no acute intracranial bleeding, and facility leadership confirmed there was no intracranial bleeding at baseline. The PA interviewed during the survey stated that increased confusion and altered mental status after an unwitnessed fall represented a significant change in condition and an emergency, and that standard clinical practice would be to obtain an immediate CT scan to rule out intracranial injury. The facility’s failure to recognize and respond in a timely manner to the resident’s significant change in condition, to initiate required frequent and systematic neurological assessments, and to ensure timely medical evaluation after the unwitnessed fall led to a delay in identification and treatment of the resident’s serious head injury. The facility’s own policies required staff to monitor and document the resident’s response following a fall, reassess and revise interventions when a fall occurred or condition changed, and perform neurological assessments upon physician order, following a fall involving head trauma, or with a change in condition. These neurological assessments were to include frequent neuro checks and vital signs, monitoring for lethargy, decreased level of consciousness, and weakness, and immediate reporting of any change in neurological status to the physician. The RCM and ADON confirmed that neuro assessments were separate from routine vital signs and required specific documentation, and that no such assessments were initiated or documented for this resident after the unwitnessed fall, despite ongoing confusion and lethargy. The PTA also confirmed that the resident required supervision for ambulation and was not safe to ambulate independently, and that unsupervised ambulation in a dark environment increased fall risk. The survey findings concluded that the facility failed to ensure adequate supervision and appropriate post-fall assessment, failed to recognize and respond to a significant change in condition, and failed to initiate required neurological assessments and timely medical evaluation, resulting in actual harm as evidenced by the resident’s subdural hematoma and subarachnoid hemorrhage.
Failure to Notify Resident Representative of Incident and Injury
Penalty
Summary
The facility failed to notify a resident's representative of an incident and a newly identified skin tear. The resident in question was admitted with multiple diagnoses, including cognitive impairment, and was documented as confused, with communication deficits that made it difficult to conduct a mental status assessment. The care plan indicated significant cognitive deficits, and the admissions record listed a family member as the resident's representative and emergency contact. On the date of the incident, the resident became agitated and combative, resulting in a skin tear on the left lower leg during a transfer to a wheelchair. A dressing was applied, and a Physician's Assistant was notified. However, there was no documented evidence in the medical record that the resident's representative was notified of either the incident or the resulting skin tear. Interviews with facility staff, including the Resident Case Manager and the Administrator, confirmed the lack of documentation and acknowledged that the family should have been notified, especially given the resident's cognitive status. Facility policy required notification of the resident's representative in such situations, but this was not followed in this case.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to ensure that comprehensive care plans were developed and implemented for several residents, leading to deficiencies in addressing their medical needs. Resident #24, who was admitted with diagnoses including pain in the left hip and an artificial hip, experienced constipation due to pain medications. Despite receiving various medications for bowel care, the resident's comprehensive care plan lacked a specific plan for managing constipation. This oversight was confirmed by the Director of Nursing, who acknowledged the absence of a care plan for constipation. Resident #134, admitted with a fracture and hematoma, was prescribed Melatonin for insomnia and Lasix for edema. However, the comprehensive care plan did not include plans for managing these conditions. The Director of Nursing confirmed that the resident should have had care plans for insomnia and edema, as they were receiving medications for these issues. The lack of care plans for these conditions was a significant oversight in the resident's care management. Resident #28, diagnosed with PTSD and metabolic syndrome, did not have a care plan addressing PTSD, despite having a history of related behaviors and being prescribed Prazosin. An incident where the resident became upset and exhibited aggressive behavior highlighted the need for a care plan. The Resident Care Manager and Assistant Director of Nursing confirmed the absence of a care plan for PTSD, which should have included specific behaviors and interventions. The facility's policies emphasized the importance of interdisciplinary and person-centered care plans, which were not adhered to in these cases.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to complete a discharge summary for a resident, which is a necessary component of ensuring continuity of care post-discharge. The resident, who had been admitted with conditions including hemiplegia, hypertension, type 2 diabetes with neuropathy, and fibromyalgia, was discharged without a comprehensive discharge summary. This summary should have included a recapitulation of the resident's stay, the treatments and services provided, and a physician's signature. The absence of this documentation was confirmed by the Social Services Director, Medical Records Clerk, and Medical Records Director. The deficiency was further highlighted when the Administrator acknowledged that the wrong template was used for the discharge, resulting in the lack of a proper discharge summary. Consequently, the resident and their family did not receive the necessary documentation regarding the resident's admission, treatments, and services provided during their stay. This oversight has the potential to impact the resident's ability to receive appropriate post-discharge care, medications, or treatments.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to ensure that a wound care nurse followed physician orders for a resident with a pressure injury. The resident, who was admitted with a fracture of the right femur, developed an unstageable pressure injury on the right knee. A physician's order was in place to cleanse the wound with normal saline, apply barrier cream, and cover it with foam dressing three times a week. However, during a wound care observation, the wound care nurse used silver alginate on the wound without obtaining a physician's order, which was not documented in the resident's clinical record. The wound care nurse admitted to using silver alginate for approximately one week without a physician's order, and the Director of Nursing Services confirmed that a physician's order was required for wound care. The facility's policy mandates verifying a physician's order before providing wound care, and the clinical record lacked evidence of such an order for the use of silver alginate. This oversight had the potential to delay the healing of the resident's wound.
Failure to Adhere to Dialysis Care Plan
Penalty
Summary
The facility failed to ensure that licensed staff adhered to a physician's order and care plan for a resident requiring dialysis, which prohibited taking blood pressure on the resident's left arm where a fistula was located. Despite the care plan and physician's order clearly stating no blood pressure should be taken on the left arm, multiple instances were documented where blood pressures were taken on the resident's left arm over a period of time. This oversight was confirmed by several staff members, including two Licensed Practical Nurses (LPNs) and the Director of Nursing (DON), who acknowledged the presence of the order and the potential harm of taking blood pressure on the arm with a fistula. The resident, who had chronic kidney disease and was dependent on renal dialysis, experienced complications with their dialysis access. An outpatient dialysis record indicated that the resident's left upper arm graft was clotted, preventing dialysis on a scheduled date, and necessitating referral to a surgery center. Subsequent surgical interventions were required to address stenosis in the graft and vein, which were treated with angioplasty. The DON confirmed that the thrombosis in the fistula led to a missed dialysis session and required surgical intervention. Despite a sign at the resident's bedside indicating no blood pressure should be taken on the left arm, the facility's failure to adhere to this directive resulted in the documented deficiency.
Medication Administration Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 25.93% due to seven medication errors out of 27 opportunities. This deficiency was identified through observation, interview, clinical record review, and document review. The specific incident involved a resident who was administered seven medications late, contrary to the facility's policy. The medications were supposed to be given at 8:00 AM, with a permissible window of one hour before or after this time. However, the medications were administered at 9:13 AM, which was beyond the allowed timeframe. The resident involved had a medical history that included cerebrovascular disease, essential hypertension, and hyperlipidemia. The medications administered late included Aspirin, Lisinopril, Protein Gel/Liquid, Cholecalciferol, Plavix, PreserVision AREDS 2+ Multivitamin, and Vitamin C. The LPN confirmed the late administration and acknowledged it did not adhere to the facility's policy. The Director of Nursing also confirmed that medication administration after 9:00 AM was considered late and did not comply with the policy, which emphasized the importance of administering medications at the right time as part of the five rights of medication administration.
Failure to Screen and Educate Resident on Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that a resident was properly screened for eligibility to receive a pneumococcal vaccine, provided with education regarding the vaccine, and offered the vaccine for administration or declination. This deficiency was identified during a review of the clinical records and confirmed by the Infection Preventionist. The resident in question was admitted and readmitted with diagnoses including iron deficiency anemia, shortness of breath, chronic obstructive pulmonary disease, and unspecified asthma. Despite these conditions, there was no documented evidence in the resident's clinical record that the necessary steps for pneumococcal vaccination were followed. The facility's policy, dated October 20, 2020, required that all residents be assessed for vaccine eligibility upon admission and offered the vaccine within 30 days if indicated. Additionally, a review of prior vaccination status was to be conducted within five working days of admission, and education regarding the vaccine's risks and benefits was to be provided. The policy also mandated documentation of the vaccination details in the resident's clinical record. However, these procedures were not adhered to for the resident, as confirmed by the Infection Preventionist, indicating a lapse in following the established vaccination protocol.
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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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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.