Marcella Post Acute

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to protect one resident, Resident #36 (R36) from a resident-to-resident altercation out of a survey sample of 42 residentsThe facility staff failed to protect R36 from a resident-to-resident altercation occurring on 11/13/25, which resulted in a left thumb fracture thus constituting harm to R36. The facility staff failed to identify and/or implement appropriate interventions, supervision, and monitoring to prevent the altercation.

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure effective pain management was provided for one resident, Resident #28 (R28), out of a survey sample of 42 residents. Specifically, the facility failed to administer the resident's prescribed pain medication as ordered. As a result, R28 experienced withdrawal symptoms, causing actual harm and discomfort.

Inspectors wroteBased on observation, staff interview, policy review and facility document review, the facility staff failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition.

Inspectors wroteBased on observation, resident interview, family interview, staff interview, and facility document review, the facility staff failed to maintain an effective pest control program to address and prevent the presence of insects throughout the facility.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to ensure the highest practicable well-being for 8 or 42 residents, Residents #29, #55, #165, #175, #15, #3, #4, and #72.

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to maintain adequate staffing levels to consistently meet resident needs.

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure provider ordered medications were available for administration for 5 of 42 residents, Residents #29, #50, #55, #165, and #3. 1. For Resident #29, the facility staff failed to ensure the provider ordered medications Peridex, Saccharomyces, and Benefiber were available for administration. Resident #29's diagnoses included quadriplegia, anxiety disorder, paralytic ileus, neuromuscular dysfunction of bladder, and cervical disc disorder. Section C (cognitive patterns) of Resident #29's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 02/17/2026 included a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. [...]

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed ensure safe and secure storage of medications and biologicals for 1 of 33 sampled residents (Resident #28), #1 of 3 medication storage rooms ([NAME]), 1 of 6 medication carts ([NAME]) and 1 treatment cart ([NAME]).

Inspectors wroteBased on observation, staff interview and facility document review, the facility staff failed to employ sufficient staff to safely and effectively carry out the functions of food and nutrition services.

Inspectors wroteBased on observation, interview and facility document review, the facility staff failed to ensure each resident receives three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care.

Inspectors wroteBased on observation, staff interview and facility document review, the facility staff failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility kitchen and in two of three nutrition rooms ([NAME] and [NAME]).

Inspectors wroteBased on resident interview, family interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure a complete and accurate clinical record for 4 of 33 residents, Resident #50, #55, #175, and #8.

Inspectors wroteBased on staff interviews, clinical record reviews and facility document reviews, the facility staff failed to treat one resident with respect and dignity. Specifically, the facility failed to protect and promote the rights of one resident, Resident #181 (R181) by applying multiple briefs with incontinence care, out of a survey sample of 42 residents.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure a clean, comfortable and homelike environment for 2 of 33 current sampled residents, Resident #3 and Resident #111.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to maintain documentation that an alleged violation of neglect was thoroughly investigated for one (1) of 42 sampled residents, Resident #63.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to provide written notification regarding the reason(s) for transfer and/or discharge to the resident and/or the resident's representative(s) and failed to offer a bed hold for 1 of 42 residents, Resident #175.

Inspectors wroteBased on observation, resident interview, staff interview and clinical record review, the facility staff failed to ensure accurate minimum data set (MDS) assessments for two (2) of 42 sampled residents, Resident #2 and Resident #36.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to complete a Level I Preadmission Screening and Resident Review (PASRR) for 1 of 33 residents, Resident #55.

Inspectors wroteBased on observation, staff interviews, resident interviews, clinical record reviews, and facility document reviews, the facility staff failed to develop and implement a comprehensive person-centered care plan for four residents, Resident #28 (R28), Resident #36 (R36), Resident #8 (R8), and Resident #9 (R9) out of a survey sample of 42 residents.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to review and revise the comprehensive person-centered care plan for 1 of 33 current sampled residents, Resident #4.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to provide activities of daily living care for 3 of 42 residents, Residents #55, #149 and #36.

Inspectors wroteBased on staff interview, clinical record review, facility document review, and facility policy review, the facility staff failed to provide an ongoing, person-centered activity program to support resident choice, interests, and physical, mental, and psychosocial well-being for one (1) of 33 current sampled residents, Resident #25.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to provide appropriate services and/or treatment to prevent further decrease in range of motion for 1 of 42 residents, Resident #55.

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to follow physicians' orders for one of 42 residents in a survey sample, Resident #8. The Findings Include: Resident #8 (R8) did not have pressure dressing supplies in place as ordered for dialysis access port. Diagnoses for R8 included diabetes, congestive heart failure, chronic pain, and end stage renal disease on dialysis. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 4/16/26. R8 was assessed with a cognitive score of 15 indicating cognitively intact. Review of R8's physician orders documented Keep pressure dressing supplies at bedside. The order was dated 5/19/26. On 5/20/2026 at 10:32 a.m. [...]

Inspectors wroteBased on observation, clinical record review, staff interviews, and facility document reviews the facility staff failed to follow a physician's order for a therapeutic diet for one resident, Resident 36, (R36) out of a survey sample of 42 residents.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to maintain a infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of diseases and infections for 2 of 3 nursing units ([NAME] and [NAME]) and 1 of 33 current sampled residents (Resident #36).

Inspectors wroteBased on staff interview, policy review, and clinical record review, the facility staff failed to ensure each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized for one of five residents sampled for immunizations, resident #134.

Inspectors wroteBased on staff interview, clinical record review and policy review, the facility staff failed to implement policies and procedures to ensure each resident or resident representative receives education regarding the risks, benefits and potential side effects associated with the COVID-19 vaccine for two of five residents in the immunization review sample, resident #134 and #163.

Inspectors wroteBased on the resident's interview, observations, family interview, staff interviews, and clinical record review, the facility's staff failed to obtain emergency dental services for one resident (Resident 7), in the survey sample.

Inspectors wroteBased on observation, resident interviews and staff interviews the facility staff failed to maintain a clean, comfortable, homelike environment for 2 of 7 residents (Resident #1 and Resident #2), in the survey sample.

Inspectors wroteBased on resident interview, staff interview, and clinical record review the facility staff failed to provide toileting hygiene/toileting assistance for 2 of 7 residents (Resident #6 and 5), in the survey sample.

Inspectors wroteBased on resident interview and staff interviews the facility staff failed to have an agreement with a dentist to provide emergency dental services for 1 of 7 residents (Resident #7), in the survey sample.

Inspectors wroteBased on observation, record review, staff interview, resident interview, interview with the facility's Pest Control Company staff, and facility policy review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests. This affected three of three units, common areas, and the dining rooms in the facility, and had the potential to affect all 126 residents residing in the facility.

Inspectors wroteBased on observation, interview, review of maintenance records, and review of facility policy, the facility failed to ensure maintenance services to maintain clean and orderly environment for residents' rooms on three of three units in the facility.

Inspectors wroteBased on interview, record review and facility policy review, the facility failed to ensure the resident, his or her family, and/or the resident representative was provided information related to the benefits and risks to the residents for psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) for five of five residents reviewed for unnecessary medications (Resident (R) 17, 31, 55, 86, and 97).

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure residents were treated with respect and dignity for three of 28 residents reviewed for respect and dignity (Resident (R) 36, R77, and R119).

Inspectors wroteBased on observations, interview, record review, and policy review, the facility failed to provide documented evidence assistance with activities of daily living (ADLs) was given to three of four residents reviewed for ADLs (Residents (R)20, R32, and R95) out of a total sample of 28 residents. Specifically, there was no documented evidence residents received showers/tub baths in accordance with the bath schedule and their needs. All three residents resided on the [NAME] unit.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to provide services to ensure two (Residents (R)63 and R4) of four residents reviewed for limited of Motion (ROM) and mobility, maintained or improved function unless reduced ROM/mobility was unavoidable based on the resident's clinical condition.

Inspectors wroteBased on observation, record review, interview, and review of facility policy, the facility failed to ensure one (Resident (R) 83) of four residents reviewed for nutrition maintained to the extent possible, acceptable parameters of nutritional status and did not experience a significant weight loss.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to ensure a resident received timely pain medication for one of 28 sampled residents (Resident (R) 62).

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to attempt use of alternatives prior to installing bed rails, failed to obtain informed consent, and failed to ensure bed rails were maintained to ensure safety for one of one sampled resident (Resident (R)20) reviewed for bed rails out of a total sample of 28 residents.

Inspectors wroteBased on record review, interview and review of facility policy, the facility failed to develop person-centered comprehensive care plans to meet resident preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs for dementia for two (Residents (R)31 and R55) of two residents reviewed with a diagnosis of dementia.

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to ensure metal boxes containing Schedule IV (controlled substances) medication located in the refrigerators in one of three medication rooms were secured in permanently affixed compartments.

Inspectors wroteBased on clinical record review, staff interviews and facility document review, the facility staff failed to convey the summary and goals of the comprehensive plan of care upon transfer/discharge for 2 of 46 Residents in the survey sample, Resident #74 and #73. 1. The facility staff failed to include in the transfer summary the resident's comprehensive care plan goals at the time of discharge/emergency department, or as soon as possible to the actual time of transfer for Resident #74 on 12/31/17, 1/10/18, 1/29/18, 2/11/18, 2/26/18, 9/5/18 and 11/11/18. 2. The facility staff failed to ensure Resident #73's comprehensive care plan goals were included in the hospital transfer documentation when the resident was transferred to the hospital on 8/20/18 and 10/8/18.

Inspectors wroteBased on clinical record review, staff interviews, and facility document review the facility staff failed to notify the office of the State Long-Term Care Ombudsman in writing of applicable discharges for 2 of 46 residents in the survey sample (Resident #74 and #73). 1. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #74's discharges to the hospital/emergency room on [DATE], 1/10/18, 1/29/18, 2/11/18, 2/26/18, 9/5/18 and 11/11/18 . 2. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #73's transfer to the hospital on 8/20/18 and 10/8/18.

Inspectors wroteBased on clinical record review, staff interviews, resident interviews and facility documentation, the facility staff failed to issue a written notice of the bed hold policy upon transfer to the local hospital for 2 of 46 residents (R #74 and #73) in the survey sample. 1. The facility staff failed to ensure Resident #74 was issued a written notice of the bed hold policy upon transfer to the local hospital/emergency department (ED) on 12/31/17, 1/10/18, 1/29/18, 2/11/18, 2/26/18, 9/5/18 and 11/11/18 . 2. The facility staff failed to provide Resident #73 or the resident representative with a written notice of the bed hold policy prior to transfer to the hospital on 8/20/18 and 10/8/18.

Inspectors wroteBased on clinical record review, staff interview and facility documentation the facility staff failed to administer a significant medication (*Dimethyl Fumarate) as ordered for 1 out of 46 residents (Resident #387) in the survey sample. The facility staff failed to administer forty doses of the *Multiple Sclerosis (MS) medication Dimethyl Fumarate as ordered by the physician.

Inspectors wroteBased on observations, record review and staff interview, the facility staff failed to maintain an effective pest control program.

Inspectors wroteBased on staff interview and clinical record review the facility staff failed for 1 resident (Resident #65) of 46 residents in the survey sample to ensure an accurate annual resident assessment. The facility staff failed to ensure that the Annual Minimum Data Set (MDS-an assessment tool), was accurately coded to reflect Resident #65 Bladder and Bowel incontinence.

Inspectors wroteBased on staff interview and clinical record review the facility staff failed to provide personal care to include showers for one resident in the survey sample (Resident #387) who was unable to independently carry out activities of daily living (ADL's). The facility staff failed to ensure Resident #387 was offered and received a scheduled twice-weekly shower to maintain good personal hygiene.

Inspectors wroteBased on observation, staff interview and clinical record review the facility failed for 1 resident (Resident #65) of 46 residents in the survey sample to provide foot care and/or ensure that Podiatry services were provided. For Resident #65, who was a Diabetic, the facility staff failed to ensure toenail care was provided. Podiatry services had not been provided since 7/31/17.

Inspectors wroteBased on observation, staff interview, and facility documentation review, the facility staff failed to ensure an opened refrigerated medication included the opened date in one of two medication rooms. The facility staff failed to date a multidose vial of influenza vaccine when opened.