Marshall Manor Nursing & Rehabilitation Center

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide a safe, clean, sanitary, comfortable, and homelike environment for 3 of 22 resident rooms. (Residents # 56, #95, #103) 1. The facility failed to provide Resident #56 with intact window coverings with no broken/damaged areas. 2. The facility failed to provide Resident #95 with a safe toilet that had an appropriate lid on the tank of the toilet. 3. The facility failed to maintain a leaking air vent affecting Resident #103. These failures could place residents at risk of an unsafe, unsanitary, uncomfortable environment, embarrassment due to rooms not appearing homelike, and a decrease in quality of life and self-worth.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident's drug regimen was free from PRN orders for psychotropic drugs and are limited to 14 days unless the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days and documents their rationale in the resident's medical record and indicate the duration for the PRN for 1 of 6 residents reviewed for unnecessary psychotropic drugs (Resident #56). 1. The facility failed to ensure Resident #56 did not have a PRN order for lorazepam 0.5 mg (a prescription medication used to treat anxiety disorders-feelings of fear, dread, and uneasiness) after 14 days without an evaluation by the physician for continued treatment with a rationale in the resident's medical record and a duration for the PRN order. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided with such care, consistent with professional standards of practices for 1 of 12 residents (Resident #14) reviewed for respiratory care. The facility failed to change the oxygen tubing and water reservoir for Resident #14. These failures could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure all drugs were stored in a locked compartment and only accessible by authorized personnel for 1 of 1 (Resident #71) residents reviewed for medication storage and 1 of 8 of medication carts. 1. The facility failed to ensure the medication cart on Hall C was locked while there were no staff around on 7/28/26. 2. The facility failed to keep medication being administered under the direct observation of the person administering medications. Resident #71 had in his possession a medication cup with an unknown red liquid in it. This failure could place residents at risk for health complications and not receiving the intended therapeutic benefit of their medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 25 resident personal refrigerators reviewed for food safety (Resident #71). The facility failed to ensure the refrigerator for Resident #71 did not contain [NAME] salami that was spoiled and out of date. This failure could place resident at risk for food borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 25 residents (Resident #31) reviewed for infection control practices. 1. The facility failed to ensure CNA G and CNA H donned (to put on) their gowns prior to providing catheter care for Resident #31, who was on enhanced barrier precautions, on 7/29/26. This failure could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents could call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 1 of 6 residents (Resident #42) reviewed for resident call system. The facility failed to ensure Resident #42 had a call light button functioning at bedside. This failure could place residents at risk of a delay in assistance and decreased quality of life, self-worth, and dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program for 1 of 2 wings reviewed for the environment. The facility did not maintain an effective pest control program to ensure the B Wing was free of roaches and water bugs. This could place residents at risk for an unsanitary environment and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to obtain physician orders for the resident's' immediate care for 1 (Resident #1) of 5 residents reviewed for admission physician orders. 1. The facility failed to obtain physician orders for the immediate care of Resident #1's surgical wound and pressure ulcer. These failures could affect residents who were admitted or readmitted to the facility by placing them at risk for not receiving the appropriate care, medication, and treatment services.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide residents with limited range of motion appropriate treatment and services to increase range of motion and to prevent further decrease in range of motion for 2 of 5 residents reviewed for range of motion. (Resident #38 and Resident #65) 1. The facility failed to provide restorative therapy for limited range of motion for Resident #38 as recommended by occupation therapy on 04/22/25. 2. The facility failed to ensure Resident #65 wore a left upper extremity splint (is a medical device that stabilizes a part of your body and holds it in place) per the facility's range of motion/contracture (is a permanent shortening or stiffening of a muscle, tendon, or joint, leading to a loss of mobility and range of motion) log on 5/5/25, 5/6/25, and 5/7/25. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 2 of 19 residents (Resident # 81 and Resident #89) and 1 of 1 Laundry room reviewed for infection control practices. 1. The facility failed to ensure CNA O changed her gloves or sanitized her hands after performing incontinent care and applying a clean brief for Resident #81. She touched a clean brief with her dirty gloves, and she touched the resident's pants with dirty gloves. 2. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 19 residents (Resident #76) reviewed for reasonable accommodations. The facility failed to ensure Resident #76 had a comfortable mattress. This failure could place residents at risk of a diminished quality of life due to an environment that is uncomfortable.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers based on the comprehensive assessment for 1 of 5 Residents (Resident #9) whose records were reviewed for skin integrity. The facility failed to ensure Resident #9's pressure-relieving mattress (is designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) was on the correct settings. This failure could place residents at risk for developing pressure ulcers and could contribute to developing avoidable pressure ulcers.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure a resident with urinary incontinence, based on the resident's comprehensive assessment, received appropriate treatment and services to prevent urinary tract infections (UTI) for 1 of 4 residents (Residents #81) reviewed for urinary catheters. The facility failed to ensure Resident #81's indwelling urinary catheter (tube inserted into the bladder to drain urine) was secured by an anchor device (used to secure an indwelling urinary catheter). The facility failed to ensure CNA O performed proper catheter care to Resident #81. These failures could place residents at risk for indwelling urinary catheter dislodgement, urethral (empties urine from the bladder and out of the body) damage, pain, and urinary tract infections.

Inspectors wroteBased on interviews and record review, the facility failed to act upon the recommendations of the pharmacist report of irregularities and to ensure the attending physician documented in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it in response to the pharmacist report for 2 of 5 residents (Resident #42 and Resident #89) reviewed for (MRR) Medication Regimen Review. 1. The facility failed to ensure a proper rationale was given for not following the pharmacy consultant's recommendation to discontinue Resident #42's Seroquel (an antipsychotic medication that treats several kinds of mental health conditions including schizophrenia and bipolar disorder) medication. 2. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements. The facility failed to ensure the CNA Class Instructor did not walk into the kitchen without a hairnet during lunch service on 05/06/25. This failure could place residents at risk of foodborne illness and food contamination.

Inspectors wroteBased on interviews, and record review, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and providing written rationale, by the provider, when an antibiotic was used despite criteria, to determine the appropriate the use of an antibiotic for 1 of 5 residents reviewed antibiotic use. (Resident #31) The facility failed to ensure Resident #31 did not receive Cephalexin (is a cephalosporin antibiotic used to treat a variety of bacterial infections) for prophylactic antibiotic use. The facility failed to ensure Resident #31's Cephalexin, ordered prophylactically, was discontinued after he was started on Cefdinir (is a cephalosporin antibiotic used to treat a variety of bacterial infections) for an active UTI. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from abuse for 1 of 6 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 did not experience physical abuse by Resident #2 on 4/5/25. The noncompliance was identified as PNC. The noncompliance began on 4/5/25 and ended on 4/6/25. The facility had corrected the noncompliance before the investigation began on 4/15/25. This failure could place residents at risk for emotional distress and further abuse.

Inspectors wroteased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 3 of 19 residents reviewed for care plans. (Resident# 13, Resident #47, Resident #73) 1. The facility failed to develop a care plan for Resident #13 and Resident #47's use of a transfer bar. 2. The facility failed to implement Resident #73's care plan intervention to wear a seizure safety helmet while out of bed on 04/09/24. These failures could place residents at risk of not having individual needs met and cause residents not to receive needed services.

Inspectors wroteased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 5 of 20 residents (Resident #32, Resident #19, Resident #47, Resident #62, and Resident # 73) reviewed for quality of care. 1. The facility failed to keep Resident #32's smoking materials locked up at the nurse's station. Resident #32's cigarette and lighter was on his bedside table in his room. 2. The facility failed to ensure Resident #19, Resident #47, Resident #62, and Resident #73 did not have objects on top of their overhead light fixtures. These failures could place residents at risk for injury, harm, and impairment or death.

Inspectors wroteBased on interview and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screening for 1 of 5 residents (Resident #73) reviewed for PASRR. The facility failed to review Resident #73's PASRR level 1 assessment for accuracy. Resident #73 had a diagnosed of bipolar disorder not reflected on PASRR Level 1. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs.

Inspectors wroteBased on interviews and record review, the facility failed to ensure each residents' drug regimen was free from unnecessary psychotropic drugs (without adequate behavior monitoring) for 1 (Resident # 25) of 5 residents whose medications were reviewed for pharmacy services in that: 1. The facility failed to ensure Resident #25 had behavior monitoring for Haloperidol (a first-generation typical antipsychotic; is used to treat nervous, emotional, and mental conditions). 2. The facility failed to ensure Resident #25 had side effect monitoring for Haloperidol. 3. The facility failed to ensure Resident #25 had documented behaviors to justify administration of Haloperidol and effectiveness of administration. These failures could place residents at risk of possible medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications.

Inspectors wroteased on observation, interview, and record review, the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #3, Resident #70) of 19 residents reviewed for infection control. The facility failed to ensure CNA F performed hand hygiene between going back and forth, several times, feeding Resident #3 and Resident #70 lunch on 04/08/24. This failure could place residents at risk for cross-contamination and the spread of infection.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from misappropriation and exploitation of property for 1 of 6 residents reviewed for misappropriation of property. (Resident #13) The facility failed to protect Resident #13 from misappropriation/exploitation by allowing two staff members to take payment/gifts from Resident #13 in return for services. This failure could place residents who resided in this facility at risk of misappropriation of property.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately for 1 of 3 residents reviewed for abuse and neglect. (Resident #24). Transportation Driver A failed to report when Resident # 24 was not properly strapped into the facility transportation van resulting in a fall from wheelchair. This failure could place residents all resident transported by the facility at risk for pain, physical harm, diminished quality of life or serious injury.