Marion Health and Rehab, LLC

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to apply a shoulder restraint during transportation in the facility van for one (1) of three (3) sampled residents (Resident #1).

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure appropriate pain management when nursing staff continued performing wound care to a resident's Stage 4 pressure ulcer after the resident verbalized pain and requested pain medication, resulting in the resident experiencing pain during the treatment for one (1) of three (3) residents reviewed for pain management. (Resident #7).

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to safeguard and ensure residents had access to their personal funds entrusted to the facility when the facility failed to deposit resident trust funds into an interest-bearing account and failed to ensure residents could access their funds following the change of ownership on 1/1/26 for three (3) of three (3) residents reviewed for resident funds (Resident #62, Resident #65, and Resident #74) and had the potential to affect all forty-three (43) residents with facility-managed trust funds.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide residents with account statements upon request for two (2) of three (3) residents reviewed for resident funds (Resident #65 and Resident #74), with the potential to affect all (43) residents with facility-managed trust funds.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure residents' rights to personal privacy and confidentiality of their medical records when resident charts containing identifying information were stored in hallways near the nurses' stations for two (2) of (2) nurses stations observed.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's right to reasonable accommodation of individual needs when the facility failed to ensure soap was available in the resident's bathroom to allow the resident to maintain personal hygiene after the installation of a wall-mounted soap dispenser for one (1) of (20) residents reviewed for resident rights. Resident #50.

Inspectors wroteBased on observation, interview, and record review, and facility policy review the facility failed to ensure residents were allowed to make choices regarding food preferences when dietary staff continued to serve pureed bread to Resident #68 after the resident had requested not to receive it and when the facility failed to accommodate Resident #49's preference for fried eggs after the facility stopped ordering eggs, affecting two (2) of (20) residents reviewed for resident choices.

Inspectors wroteBased on interview, record review and facility policy review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment when the facility coded an antipsychotic medication on the MDS despite no physician orders or Medication Administration Record (MAR) documentation for an antipsychotic medication for one (1) of (20) residents reviewed for MDS accuracy. (Resident #12).

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide an ongoing activities program designed to meet the interests and preferences of residents when scheduled weekend activities were not conducted and residents reported limited opportunities for activities on weekends, for one (1) of (20) residents reviewed for activities (Resident #74), which affected all residents who participate in activities.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to follow the posted menu as written and failed to ensure alternate menu items were available as listed on the menu for two (2) of (20) residents reviewed for food services. Residents #65 and #74.

Inspectors wroteBased on observation, staff interview, record review, facility investigation review, and facility policy review, the facility failed to implement comprehensive care plan interventions related to resident transfers when a Certified Nurse Aide (CNA) transferred a resident without assistance, using the incorrect sling size, which resulted in the resident falling during the transfer, receiving a fracture and head laceration for one (1) of four (4) care plans reviewed.

Inspectors wroteBased on observation, interviews, record review, facility investigation review, and facility policy reviews the facility failed to ensure a resident was transferred safely while using a mechanical lift when a Certified Nurse Aide (CNA) performed the transfer without assistance and used the incorrect sling size, which caused the resident to fall, resulting in a fracture and head laceration for one (1) of four (4) sampled residents. (Resident #1)

Inspectors wroteBased on interviews, record review, and facility policy review the facility failed to ensure resident council members' complaints regarding food that was served cold were recorded and resolved in a timely manner for nine (9) of 11 Resident council members. (Resident #4, #18, #20, #27, #42, #49, #52, #62, and #68)

Inspectors wroteBased on observation, interviews, record review, and facility's policy review the facility failed to ensure resident's food was served at an appetizing temperature for one (1) of 15 sampled residents. This had the potential to affect 74 residents receiving food from the kitchen. (Resident # 38)

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to accurately complete the Minimum Data Set (MDS) assessments for residents who were discharged from the facility for two (2) of 18 residents reviewed. (Resident #77 and Resident #79)

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure vision services were provided for a resident who was visually impaired for one (1) of 15 sampled residents.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to ensure the chemical sanitizer for a low-temperature dishwasher had a concentration of at least 50 parts per million (ppm) for one (1) of two (2) dishwasher observations. Findings Include: Review of the facility's policy, Sanitization with a revision date 10/04/22, revealed, The food service area will be maintained in a clean and sanitary manner. Policy Interpretation and Implementation .3. All equipment, food contact surfaces and utensils will be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and or chemical sanitizing solutions .6. Dishwashing machines must be operated using the following specifications .Low-Temperature Dishwasher (Chemical Sanitization) .b. [...]

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to provide evidence that residents refused the Influenza and/or Pneumococcal vaccine for two (2) of five (5) residents reviewed for immunizations.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to provide evidence that residents refused the COVID-19 vaccine for two (2) of five (5) residents reviewed for immunizations.

Inspectors wroteBased on the interview, record review, and facility policy review, the facility failed to notify the Resident Representative (RR) when a resident required a change in the level of care and required one-on-one (1:1) supervision due to confusion for one (1) of four (4) residents reviewed. Resident #1. Findings Include: A review of the facility's policy, Notification of Change in a Resident's Condition or Status, revised 8/2/22, revealed .Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care) .Policy Interpretation and Implementation .5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status . [...]

Inspectors wroteBased on staff and Resident Representative interviews, record review, and facility policy review, the facility failed to protect the resident's right to be free from neglect when staff provided inaccurate body audits and services for one (1) of four (4) sampled residents. Resident #1 The facility's failure to ensure that body audits were completed accurately resulted in Resident #1 sustaining an amputation of the fifth digit of her right foot and placed other residents in a situation that was likely to cause serious injury, serious harm, serious impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 10/18/23 when facility staff completed an inaccurate weekly body audit. The facility Administrator was notified of the IJ and SQC on 11/15/23 at 12:12 PM and was presented with the IJ Template. [...]

Inspectors wroteBased on interviews, record reviews, and facility policy reviews, the facility failed to implement comprehensive care plan interventions related to skin assessments for one (1) of four (4) sampled residents. Resident #1 The facility's failure to implement a care plan for weekly body audits and ensure the body audits were completed accurately resulted in Resident #1 sustaining an amputation of the fifth digit of her right foot and placed other residents in a situation that was likely to cause serious injury, serious harm, serious impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 10/18/23 when facility staff completed an inaccurate weekly body audit. The facility Administrator was notified of the IJ on 11/15/23 at 12:12 PM and was presented with the IJ Template. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to identify and provide treatment to an open scalp wound for one (1) of four (4) sampled residents. Resident #1 Findings Include: Review of the facility's policy, Abuse Prevention Program, undated, revealed, .Our residents have the right to be free from .neglect . Review of the facility's policy, Skin Assessment revised 11/1/2022, revealed .It is our policy to perform a full body skin assessment as part of our systemic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment .Policy Explanation and Compliance Guidelines: 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/ re-admission and weekly thereafter . [...]

Inspectors wroteBased on interview, record review and facility policy review, the facility failed to implement comprehensive care plan interventions related to skin assessments for one (1) of four (4) sampled residents. Resident #1 Findings Include: Review of the facility's policy, Comprehensive Care Plans, revised 8/24/22, revealed, .It is the policy of this facility to .implement a comprehensive person-centered care plan for each resident .to meet a resident's medical, nursing, and mental and psychosocial needs .Policy Explanation and Compliance Guidelines .8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions . Record review of the Comprehensive Care Plan revealed a Focus of Resident has a dx (diagnosis) of carcinoma .of skin of scalp ., with a revision date of 7/11/2023. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to accurately code a Minimum Data Set (MDS) assessment for a resident with a restraint for one (1) of 24 MDS assessments reviewed. Resident #16 Findings Include: The facility's policy Resident Assessment Instrument (undated), revealed .Any flags for this MDS section will be reviewed and resolved prior to submission of the MDS to ensure accuracy of MDS .All persons who have completed any portion of the MDS Resident Assessment Form MUST sign such document attesting to the accuracy of such information . [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to follow a resident's comprehensive care plan for one (1) of 24 care plans reviewed for implementation of identified interventions. Resident #68. Findings Include: Record review of the facility's policy, Comprehensive Care Plan, undated, revealed It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident .to meet a resident's medical, nursing, and mental and psychosocial needs . Record review of the admission Record revealed Resident #68 was admitted to the facility on [DATE] with a diagnosis of Major Depressive Disorder and Generalized Anxiety Disorder. Record review of the Comprehensive Care Plan revealed Resident #68 uses anti-anxiety medications related to Anxiety. [...]

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to ensure privacy curtains in resident rooms were clean for four (4) of 24 sampled residents. Resident #1, Resident #61, Resident # 62, and Resident #64. Findings Include: A review of the facility's policy Routine Cleaning and Disinfection (undated) revealed Policy: It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible .Policy Explanation and Compliance Guideline .13. Privacy curtains in resident rooms will be changed when visibly dirty by laundering or cleaning with per manufacturer's instructions . [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to prevent a significant medication error by not reordering a prescribed medication for one (1) of 24 sampled residents. Resident #68 Findings Include: Record review of the facility's policy, Medication Orders and Receipt Record, undated, revealed, .Policy Interpretation and Implementation .4. Medications should be ordered in advance, based on the dispensing pharmacy's required lead time. Five days for reorder medications and seven days for medication that requires special processing . On 08/22/22 at 12:15 PM, in an interview with Resident # 68, he stated he did not receive his anxiety medication (Xanax) this past weekend (08/20/22 and 08/21/22) and the nurses told him that the Nurse Practitioner (NP) did not write a prescription for the medication. He had to deal with anxiety all weekend. [...]