Marshall Nursing and Rehabilitation Community

Inspectors wroteThis citation pertains to Intake 3000710. Based on interview and record review, the facility failed to ensure five of five licensed nurses had the necessary competency evaluations as identified in the facility assessment.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from of physical abuse by a staff member.

Inspectors wroteBased on interview and record review the facility failed to report to the state agency abuse against one out of three residents (R1). Per the facility face sheet Resident #1 (R1) was an [AGE] year-old who was originally admitted to the facility on [DATE] with a return to the facility date of [DATE]. Diagnosis included Alzheimer's disease, bipolar disorder, dementia, and anxiety. Review of a Physician's progress note dated [DATE] revealed R1 expired and had a time of death of 3:34 PM (actual time was 2:34 PM) on [DATE]. Review of a progress note dated [DATE] revealed a phone call was made to R1's guardian at approximately 2:20 PM to discuss R1's change in condition and the assessment made by Medical Director (MD) C. [...]

Inspectors wroteBased on interview and record review the facility failed to report to investigate abuse against one out of three residents (R1). Per the facility face sheet Resident #1 (R1) was an [AGE] year-old who was originally admitted to the facility on [DATE] with a return to the facility date of [DATE]. Diagnosis included Alzheimer's disease, bipolar disorder, dementia, and anxiety. Review of a Physician's progress note dated [DATE] revealed R1 expired and had a time of death of 3:34 PM (actual time was 2:34 PM) on [DATE]. Review of a progress note made by Director of Nursing (DON) B revealed Guardian E was notified regarding a bruise to R1's right shin. The note revealed that during the shower R1 began to be aggressive with staff and hit her leg on the shower chair which caused a bruise. An X-ray was ordered. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food brought in by outside family and/or visitors that was stored in the resident refrigerators were labeled and dated,Findings Included: This citation pertains to intake number 2747062. During an observation on 3/3/2026 at 3:30 PM, with Director of Nursing (DON) B of the refrigerator on [NAME] south revealed a large and small box of outside delivery pizza that had no labeling, no date, no expiration date, and no resident name, On the [NAME] hall it was observed in the refrigerator a bag of tacos from an outside restaurant that had a date on the receipt as received on 2/27/2026, which was past the expiration date; [...]

Inspectors wroteBased on observation and interview the facility failed to ensure infection control practices were maintained for two out of three (Resident 7 and 9) catheter bags. Findings Included:This citation pertains to intake number 2787832. Resident #7 (R7):In an observation on 3/3/2026 at 9:47 AM R7 was observed lying in bed asleep. R107 had a catheter bag which was on the side of the bed next to window. The catheter bag was laying 100% on the floor and was not attached to the bed. Review of R7's care plans revealed a care plan was in place for Indwelling Catheter. The care plan had an intervention dated 9/11/2025 of, Do not allow tubing or any part of the drainage system to touch the floor. Resident #9 (R9):On 3/3/2026 at 9:44 AM, R9 was observed in bed, and also observed to have a catheter bag hanging on the side of the bed with bottom of bag laying on the floor. [...]

Inspectors wroteThis citation pertains to intake 2685929. Based on interview and record review, the facility failed to implement care plan interventions for one (R2) of three reviewed.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain best practices in accordance with professional standards of food service safety. The deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide meaningful and engaging activities of interest for two of two residents reviewed (Resident #2 and Resident #6), and failed to provide activity programming during the week, potentially affecting the total census of 46. Resident #2 (R2) Review of the medial record revealed R2 was admitted to the facility 01/08/2021 with diagnoses that included type 2 diabetes, frontotemporal neurocognitive disorder (type of dementia), legal blindness, polyosteoarthritis (arthritis in five or more joints), diabetic polyneuropathy (weakness, numbness, and pain from nerve damage caused by diabetes), obesity, lymphedema (swelling caused by blocked lymphatic system), tachycardia, bradycardia, chronic kidney disease, and anemia (low red blood cells). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility Activity Director met the criteria as a qualified activities professional in a current facility census of 46 residents. Upon observation of the main hallway of the facility on 09/02/25 it had a large board that was to post the Activities for the week. However, the board was blank and the Activity calendar was not posted until 09/04/2025. Review of the September activity Calendar offered activities 7 days a week, the latest activity held was 3:30 PM. Some of the titled Activities were Morning News, Church Packets Conversation ball. There were zero activities observed during the survey week of 9/02-09/08/25. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to conduct monthly pharmacy reviews for one resident (#5) of five resident reviewed for pharmacy services and the facility failed to implement/respond to pharmacy recommendations for four residents (#3, #5, #28, #46) of five residents reviewed for pharmacy services. Review of the medical record reflected R46 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included need for assistance with personal care. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/19/25, reflected R46 scored 12 out of 15 (moderately impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 9/9/25 at 1:30 PM, R46 was observed in her room. R46 was in bed and was pleasant and nicely groomed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program. Findings Include:Resident 104-1 (R104-1) Review of the medical record reflected that R104-1 was admitted to the facility on [DATE], hospitalized on [DATE] and was readmitted to the facility on [DATE]. Diagnoses of Displaced [NAME] fracture of left tibia, subsequent encounter for closed fracture with routine healing, need for assistance with personal care, Unsteadiness on feet. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE] revealed R104-1 had a Brief Interview of Mental Status (BIMS) of 15 (Cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R104-1 needed assistant with personal care. [...]

Inspectors wroteBased on observation and interviews, the facility failed to maintain a safe, functional, sanitary, and comfortable environment. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living. Findings Include:On 9/2/25 at 1:44 PM, observation of the Forest Unit spa room found three call lights in the room, two of the call lights had pull cords 18 to 28 inches off the ground and the third call light (in the far shower) did not have a pull cord at all. Further observation of the spa room found a nickel sized sticker on the shower wall with an image of a snowflake and three clean washcloths open and exposed on the rack in the first shower stall. On 9/2/25 at 1:58 PM, observation of the [NAME] Unit soiled utility room, found two boxes of gloves and two rolls of trash bags in the hand sink. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to honor a resident's/guardian (#4) Advance Directives (a written statement of a resident's wishes regrading medical treatment) for DNR (Do not Resuscitate) of one residents reviewed. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or resident's representative of the facility policy for bed hold and a written reason for the transfer, for one (Resident #50) and failed to provide notice of discharges and transfers, to the representative of the Office of the State Long-Term Care Ombudsman for two of two residents reviewed (Resident #50 and #52).

Inspectors wroteBased on observation, interview, and record review the facility failed to submit a significant change Minimum Data Set (MDS) for one (Resident #13) out of 12 reviewed for significant change MDS.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for one resident (#25) of 12 residents reviewed for accurate assessments. Findings Included:Resident #25 (R25) Review of the medical record revealed R25 was admitted to the facility 08/27/2016 with diagnoses that included Parkinsonism (a group of neurological disorders that share similar symptoms to Parkinson's disease), seizures, disorders of psychological development, type 2 diabetes, anemia (low red blood cells), anxiety, bipolar disorder, hypothyroidism (low thyroid hormone), peripheral vascular disease (PVD), gastro-esophageal reflux disease, constipation, Parkinson's disease, malnutrition, dementia, and dysphagia (difficulty swallowing). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure showers were provided on a routine, regularly scheduled basis and as preferred for one resident, (Resident #6) of one reviewed.

Inspectors wroteBased on interview and record review, the facility failed to initiate Cardiopulmonary Resuscitation efforts in a timely manner for one (Resident #51) of one reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement pressure wound treatment orders in a timely manner for one (Resident #13) out of one reviewed for pressure wounds.

Inspectors wroteBased on observation, interview, and record review the facility failed to label medication with open dates in two of three medication carts reviewed and failed to record refrigerator temperatures for two or two medication refrigerators reviewed. Finding Included:On 09/08/2025 at 10:04 a.m. during inspection of [NAME] North medication cart, with Licensed Practical Nurse (LPN) W, it was observed that the following medication was open and did not have a date that they were opened recorded on the medication container: Trelegy 100mcg(micrograms)/62.5mcg/25mcg inhalers, and two Albuterol Sulfate inhalers 90mcg. During an interview on 09/08/2025 at 10:05 a.m. Licensed Practical Nurse (LPN) W explained that it was the facility practice to date all medication once it is open. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide dental services for one resident (8) out of one resident's review for dental services. Findings Included:Resident #8(R8) Review of the medical record revealed R8 was admitted to the facility 12/31/2024 with diagnoses that included bipolar disorder, type 2 diabetes, hypertension, hyperlipidemia (high fat content in blood), gastro-esophageal reflux disease, restless leg syndrome, paranoid schizophrenia, chronic pain, anxiety, depression, and obesity. Review of the most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/07/2025, demonstrated a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on R8 was observed lying in bed. R8 was observed edentulous (without teeth). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to offer the influenza immunization to one (Resident #13) out of 5 reviewed for immunizations.

Inspectors wroteBased on observation, interview, and record review the facility failed to offer the COVID-19 immunization to one (Resident #13) out of 5 reviewed for immunizations.

Inspectors wroteThis citation pertains to intake number 2580873. Based on interview and record review the facility failed to ensure for one out of three residents (Resident #2) Physician's orders were followed to ensure diagnostic testing was performed for proper treatment and prevent hospitalization. R2 no longer resided at the facility at the time of the investigation. Per the facility face sheet Resident #2 (R2) was admitted to the facility on [DATE]. R2 had a diagnosis of Personal history of urinary (tract) infections (UTI). Record review of R2's care plans dated 8/31/2023, revealed R2 received prophylactic (preventative) antibiotics due to chronic urinary tract infections. Review of a Nurse Practitioner progress note dated 5/20/2025, revealed documentation that R2 had increased confusion, and a urine sample would be obtained. [...]

Inspectors wroteBased on interview and record review, the facility failed to assess, monitor, follow physician orders and document on skin wounds for one (R101) of three residents reviewed for non-pressure skin conditions.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure controlled medications were properly labeled and stored per professional standards of practice for one residents (R104) and a medication cart in a current facility census of 45 residents. Findings Included: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R104 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease, pneumonia, weakness and depression. The MDS reflected R104 had a BIM (assessment tool) score of 14 which indicated her ability to make daily decisions was cognitively intact. Review of complaint received by the State Agency alleged the facility failed to appropriately store controlled medications. [...]

Inspectors wroteThis citation pertains to intake MI00149290 Based on observation and interview the facility failed to maintain documentation to indicate glucometer calibration was being performed potentially affecting all residents (17) who were diagnosed with diabetes with ordered monitoring resulting in the potential for inaccurate blood glucose readings and incorrect treatment.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain disinfection for glucometer's (blood glucose testing devices) affecting residents (R4, R5, R8, and R9) of 4 residents reviewed resulting in the potential for bacterial growth and transmission of pathogens.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the development of pressure injuries, including a medical device-related pressure injury, for one resident (Resident #26) out of 4 reviewed for pressure injuries. This deficient practice resulted in resident experiencing harm due to facility-acquired pressure injuries.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pain medications were given as ordered for one (resident #26) of two reviewed for pain, resulting in resident experiencing harm with uncontrolled pain.

Inspectors wroteBased on interview and record review the facility failed to ensure resident emergency transfer notifications were sent to the State Long-Term Care Ombudsman over the last for 41 residents, resulting in the potential for residents being inappropriately transferred or discharged . Findings Included: In an interview on 9/19/2024 at 9:15 AM, the State Long-Term Care Ombudsman R stated she had not received any copies of notifications of resident emergency transfers out of the facility for the last year, and stated she had inquired about them several times to the facility, but had not received any answer nor copies. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 49 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and cross-connections between the potable (drinking) and non-potable (non-drinking) water supplies.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively maintain the outdoor waste receptacle effecting 49 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and pest attraction/harborage.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 49 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased air quality.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications/treatment carts remained secured in 2 of 3 medication/treatment carts reviewed, resulting in the potential unsafe access to medications. On 9/18/24 at 12:10 PM, two treatment carts located in the resident's dining room (North [NAME]) were observed to be unlocked. The cart drawers were opened revealing wound treatment supplies, including several prescribed topical medications. On 9/19/24 at 9:01 AM, the same treatment carts remained unlocked. On 9/19/24 at 10:24 AM, the same treatment carts remained unlocked. On 9/19/24 at 12:21 PM, one of the treatment carts was observed to be unlocked. The cart drawers were opened revealing wound treatment supplies, including several prescribed topical medications. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide palatable food products effecting 49 residents, resulting in the increased likelihood for resident decreased food acceptance and nutritional decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective system to correct and monitor deficiencies for range of motion/mobility (F688) for two (Resident #31 and Resident #503), medication labeling/storage (F761), and environment (F921) that were identified on the previous survey dated 9/20/24, and ensure the facility was in compliance by the facility's alleged compliance date of 10/17/14.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure safe and clean medical equipment (wheelchair) for one resident (#20) out of 15 residents reviewed. Findings Included: Resident #20 (R20) Review of the medical record revealed R20 was admitted to the facility 11/05/2019 with diagnoses that included Alzheimer's Disease, dysphagia (difficulty swallowing), need for assistance with person care, stage 3 kidney disease, insomnia, repeated falls, osteoarthritis (chronic disease causing breakdown of cartilage in bone joints), major depression, anxiety, epilepsy, anemia (low red blood cells), and hypothyroidism (low thyroid hormone). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/10/2024, demonstrated a Brief Interview for Mental Status (BIMS) of 2 (severe cognitive impairment) out of 15. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to complete accurate Minimum Date Set (MDS) assessments for 1 Resident (#33) (use of restraints) of 15 Residents reviewed for accurate MDS Assessments. Findings Included: Resident #33 (R33) Review of the medical record revealed R33 was admitted to the facility 01/17/2019 with diagnoses that included cerebral infarction (stroke), hemiparesis (difficulty moving one side of the body) of the left side, hemiplegia (paralysis one side of the body) of the left side, aphasia (difficulty speaking), dysphagia (difficulty swallowing), weakness, expressive language disorder, type 2 diabetes, contracture of the left knee, contracture of the left elbow, contracture, of the left hand, contracture of the left wrist, contracture of the left hand, hypertension, major depression, muscle spasm and chronic pain. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to complete and provide a baseline care plan within 48 hours of admission for one Resident (#22) of 1 reviewed for baseline care plan development. Findings Included: Resident #22 (R22) Review of the medical record revealed R22 was admitted to the facility 09/09/2024 with diagnoses that included iron deficiency anemia (low red blood cells), end stage renal disease, depression, weakness, need for assistance with personal care, abnormalities with gait and mobility, heart failure, peripheral vascular disease (PVD), type 2 diabetes, dependence on renal dialysis, severe protein-calorie malnutrition, and atrial fibrillation. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/13/2024, demonstrated a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) of 15. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure hand, elbow, and knee splints were placed on and off as directed for one resident (Resident #31) out of one sample for mobility resulting in the potential for worsening of contractors. Findings Include: Per Resident #31's (R31) diagnoses list R31 had contractures of the right elbow, left elbow, right hand, left hand, right lower leg, left lower leg, right knee, left knee, right ankle, and left ankle. On 9/18/2024, at 10:53 AM, R31 was observed In bed with pillows under her knees lying flat on her back. Both of her arms and hands were observed to be contracted. Knee, hand and other splints were observed on a chair in the room. Inside R31's closet door was a posted note attached to the door that instructed to put both knee braces on R31 daily up to or less than 4 hours each time. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain weights per policy in one of two residents reviewed for nutrition (Resident #26), resulting in the likelihood of inaccuracy of the individual's nutritional status.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper storage, cleaning and labeling of oxygen/respiratory equipment for two Resident(R18 and R37), of two residents reviewed for oxygen and respiratory care, resulting in the likelihood for cross contamination, respiratory illnesses/disease and increased antibiotic usage.

Inspectors wroteBased on observation, interview and record review the facility failed to provide ongoing communication and collaboration with the contracted dialysis facility regarding dialysis care for one resident (#29) of one resident reviewed resulting in ineffectively tracking weights and the potential for unmet care needs. Finding Include: Resident #29 (R29) Review of the medical record revealed R29 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included end stage renal disease and a binge eating disorder. Review of the Minimum Data Set revealed R29 received dialysis services. On 9/18/24 at 1:12 PM, R29 was observed in his room. R29 reported no concerns with his dialysis care, however, reported that sometimes the dialysis place doesn't send back the filled-out forms. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that bed rails were assessed and measured to prevent possible entrapment for one Resident (#33) of one resident reviewed for Residents using bed rails. Findings Included: Resident #33 (R33) Review of the medical record revealed R33 was admitted to the facility 01/17/2019 with diagnoses that included cerebral infarction (stroke), hemiparesis (difficulty moving one side of the body) of the left side, hemiplegia (paralysis one side of the body) of the left side, aphasia (difficulty speaking), dysphagia (difficulty swallowing), weakness, expressive language disorder, type 2 diabetes, contracture of the left knee, contracture of the left elbow, contracture, of the left hand, contracture of the left wrist, contracture of the left hand, hypertension, major depression, muscle spasm and chronic pain. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate less than 5% resulting in an error rate of 16%. Findings Included: During an observation on 9/19/2024 at 7:50 AM, of medication administration, Registered Nurse (RN) T was observed to put five pills into a medication cup that she had put a spoonful of pudding into. One of the pills RN T was observed to put in the medication cup was a Hyoscyamine 0.25 mg tablet (used for stomach issues). RN T was then observed to administered the pudding with all five of the pills into R38's mouth, and observed R38 to swallow the pudding and the pills. Review of R38's medication administration record revealed the order RN T administered for the Hyoscyamine 0.25 mg pill was ordered to be administered sublingual, meaning place under the tongue to dissolve, and not swallow. [...]

Inspectors wroteDuring observation and interview, the facility failed to provide alternative food choices for 3 Residents (#13, 26,41) resulting in the potential frustration of residents and a non-pleasurable dining experience. On 9/18/24 at 9:19 AM, Resident #26 (R26) was observed in his room, resting in bed. R26 was conversant, demonstrated a clear understanding of questions, and responded appropriately. R26 reported that he did not care for the taste of the food at the facility, stating that often times he would not consume any breakfast and would refuse a meal at least once a week. When asked if there was alternative food items available, R26 stated I think there's just a peanut butter and jelly sandwich. R26 stated that no one had ever discussed his food like and dislikes with him. On 9/18/24 at 10:08 AM, Resident #41 (R41) reported that the food at the facility was not good. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to coordinate hospice services for one resident (#38) out of one resident reviewed for coordination of hospice services resulting in the potential for care note being provided to resident receiving hospice services and the potential for residents not to be fully informed of hospice services provided. Findings Included: Resident #38 (R38) Review of the medical record revealed R38 was admitted to the facility 10/29/2021 with diagnoses that included pneumonia, frontotemporal neurocognitive disorder, dysphagia (difficulty swallowing), muscle weakness, need for assistance with personal care, dementia, anxiety, insomnia, depression, chronic obstructive pulmonary disease (COPD). [...]

Inspectors wroteThis citation pertains to intakes: MI00145052, MI00145688 Based on observation, interview, and record review the facility failed to follow Enhanced Barrier Precautions (EBP), an infection control intervention designed to reduce transmission of multidrug-resistant organisms, for one Resident (#6) out of three resident reviewed for the appropriate use of infection control standards. Findings Included: [...]

Inspectors wroteThis citation pertains to intake MI00144513. Based on interview and record review, the facility failed to ensure background checks were completed prior to the start of employment for newly hired staff, with the potential to effect the 49 residents that resided in the facility at the time of the survey.

Inspectors wroteBased on interview and record review the facility failed to ensure that four Certified Nurse Aides (CNA) )(N, P, Q, and R) and one Registered Nurse (RN) (O) had the required initial competency evaluations and one CNA Q annual competency evaluation, including demonstration in skills and techniques necessary to care for Residents resulting in the potential for staff to lack in the necessary training to adequately meet the needs of 49 Residents that currently reside at the facility. Findings Included: Record review of facility staff personnel records demonstrated Certified Nursing Aide (CNA) N was hired 03/14/2024. CNA N's personnel records did not demonstrate any initial competency evaluation after date of hire. Record review of facility staff personnel records demonstrated Certified Aide (CNA) P was hired 11/06/2023. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide showers as ordered for two (Resident #6 and #7) of three reviewed.

Inspectors wroteBased on interview and record review the facility failed to ensure that one Certified Nursing Aide (CNA) (Q) of four CNA's reviewed received annual performance evaluations to adequately meet the needs of the 49 Residents that currently reside at the facility. Findings Included: Record review of facility staff personnel records demonstrated Certified Aide (CNA) Q was hired 02/08/2022. CNA Q's personnel records did not demonstrate an annual performance evaluation for 02/2023 or 02/2024. During an interview on 05/24/2024 at 02:13 p.m. Business Office Manager (BOM) M confirmed that Certified Nurse Aide (CNA) Q did not have an annual performance evaluation for 2/2023 or 2/2024. He explained that it is the expectation that all employees receive an annual performance evaluation in their annual month of hire. BOM M could not explain why CNA Q had not had annual performance evaluations completed.

Inspectors wroteBased on interview and record review the facility failed to ensure two Certified Nurse Aide (CNA) (N,P) out of five reviewed were trained in the facility expectation on caring for Residents which included effective communication, resident rights and facility responsibilities, abuse/neglect and exploitation, and infection prevention to adequately meet the needs of 49 Residents that currently reside at the facility. Findings Included: Record review of facility staff personnel records demonstrated Certified Nursing Aide (CNA) N was hired 03/14/2024. Review of CNA N employee personnel filed did not demonstrate that any education had been completed since date of hire. Education was not present for effective communication, resident rights and facility responsibilities, abuse/neglect and exploitation, and infection prevention. [...]

Inspectors wroteBased on interview and record review the facility failed to meet the required 12-hour educational requirements for one Certified Nursing Aide (CNA) (Q) out of five CNA's reviewed to adequately meet the needs of the 49 Residents that currently reside at the facility. Findings Included: Record review of facility staff personnel records demonstrated Certified Aide (CNA) Q was hired 02/08/2022. CNA Q personnel records did not demonstrate that she had received 12 hours of in-service training. During an interview on 05/24/2024 at 02:13 p.m. Business Office Manager (BOM) M confirmed that Certified Nurse Aide Q personnel records did not contain 12 hours of in-service training. He explained that the 12 hours had been assigned but that none of those hours had been completed during her last year or employment. BOM M could not explain why the 12 hours assigned had not been completed.

Inspectors wroteBased on interview and record review the facility failed to ensure that two Certified Nursing Aides (N, P) out of five direct care staff had behavioral health training to adequately meet the needs of 49 Residents that currently reside at the facility. Findings Included: Record review of facility staff personnel records demonstrated Certified Nursing Aide (CNA) N was hired 03/14/2024. Review of CNA N employee personnel filed did not demonstrate that any education had been completed since date of hire. Education was not present for behavioral health training. Record review of facility staff personnel records demonstrated Certified Aide (CNA) P was hired 11/06/2023. Record review of facility staff personnel records demonstrated Certified Aide (CNA) P was hired 11/06/2023. Review of CNA P employee personnel filed did not demonstrate that any education had been completed since date of hire. [...]

Inspectors wroteThis citation pertains to intake number MI00142697. Based on interview and record review the facility failed to ensure one out of three residents (Resident #2) was free from abuse. Findings Included: In an interview on 3/12/2024 at 11:00 AM, Resident #2 (R2) stated that one time when she was being straight cathed (tube inserted into the bladder to drain urine then removed) and was exposed with her legs open in her bed, and upon a nurse leaving her room curtain and door were left open exposing her uncovered private area to anyone outside of her room. R2 said another nurse was holding her labia (flaps of skin on either side of the vagina) open during this time so she was not covered up. During the interview R2 began to cry and stated that she was humiliated, vulnerable, upset, scared, and felt threatened. [...]

Inspectors wroteThis citation pertains to intake numbers MI00142630 and MI00142697. Based on observation, interview, and record review the facility failed to develop a comprehensive pressure ulcer care plan for two of three residents (Resident #1 & 2). Findings Included: Resident #1 (R1) Per the facility face sheet R1 was admitted to the facility on [DATE]. Diagnoses include right above the knee amputation and paraplegia. Review of a vascular (vein/artery system) Physician's (Patient Discharge Summary revealed R1 was admitted from the facility to the hospital 12/27/2024 for a right above the knee amputation. The summary revealed under discharge orders Additional Transfer Instructions, Wound site(s): left heel -Cleans wound with mild soap and water/saline, rinse well, pat dry -Apply Calcium Alginate to wound. (Cut to size.) -Cover with a mepilex border. [...]

Inspectors wroteThis citation pertains to intake Numbers MI00142729 and MI00142697 Based on observation, interview, and record review, the facility failed to 1) write a physician order for a laboratory (lab) test and document a resident assessment, rationale for lab test, and completion of the lab draw procedure for one resident (Resident #4) and 2) failed to administer medications as ordered by the physician, and maintain infection control prevention during catheterization for one resident (Resident #2) of 5 reviewed, resulting in residents not receiving care and treatment in accordance with professional practice and the potential for worsening medical conditions.

Inspectors wroteThis citation pertains to intake numbers MI000142729, MI00142630, & MI00143199. Based on observation, interview, and record review the facility failed to provide the necessary treatment and services for pressure ulcer for three out of three residents (Resident #1, 2, & 4) to promote healing and prevent infection. Findings Included: Resident #1 (R1) Per the facility face sheet R1 was admitted to the facility on [DATE]. Diagnoses include right above the knee amputation and paraplegia. Review of a vascular (vein/artery system) Physician's (Patient Discharge Summary revealed R1 was admitted from the facility to the hospital 12/27/2024 for a right above the knee amputation. The summary revealed under discharge orders Additional Transfer Instructions, Wound site(s): left heel -Cleans wound with mild soap and water/saline, rinse well, pat dry -Apply Calcium Alginate to wound. [...]

Inspectors wroteThis citation pertains to intake MI00137735 and MI00137656 Based on interview and record review, the facility failed to 1) ensure the emergency Ambu-bag was at the bedside 2) failed to provide timely cardio-pulmonary resuscitation (CPR) according to standards of practice for one (Resident #3) of one reviewed for emergency resuscitation, resulting in an Immediate Jeopardy when R3 was discovered unresponsive without pulse or respirations with a full 3 minute delay prior to the initiation of CPR resulting in death and 3) failed to ensure current Cardio-pulmonary Resuscitation (CPR) certification for 3 licensed nursing staff (received online training only) resulting in the potential for the 32 facility residents who are Full-Code to not being resuscitated during a cardiopulmonary arrest.

Inspectors wroteThis citation pertains to intake numbers MI00138798 and MI00137463 Based on observation, interview and record review the facility failed to provide sufficient staffing to ensure resident needs were met timely for 2 (#3, #6) of 7 sampled residents resulting in unmet care needs and the potential for unmet care needs for all 53 residents residing in the facility.

Inspectors wroteThis citation pertains to intake # MI00137463 Based on observation and interview, the facility failed to maintain a functional, clutter free environment in the common areas potentially effecting all 53 residents, resulting in the likelihood of injury and an uncomfortable, nonhome-like environment. On 10/5/23 at 1:04 PM, the [NAME] unit was observed to contain 2 beds in the Dining/day room, multiple carts containing nursing equipment, a floor dryer on a table, wheelchairs and plastic bags containing clothing. Additionally, the [NAME] hallway contained multiple wheelchairs, Broda chairs (padded, reclining wheelchairs), 2 mechanical lifts, multiple walkers, wheelchair foot pedals on the floor, a pair of black shoes, a cardboard box, and a bundle of towels. [...]

Inspectors wroteThis citation pertains to Intake Number MI00136163 Based on interview and record review, the facility failed to provide an effective bowel management program for one (Resident #1) of three reviewed, resulting in the potential for constipation.

Inspectors wroteThis citation pertains to intake MI00137735 and MI00137656 Based on observation, interview and record review, the facility failed to provide tracheostomy care and suctioning according to standards of practice for one (Resident #3) of three reviewed for tracheostomy care, resulting in the potential for respiratory distress and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain hand washing cleanser availability, maintain physical facility, and label chemical bottles, resulting in the potential biological and chemical contamination of food, affecting all residents that consume food from the kitchen.

Inspectors wroteBased on observation and interview the facility failed to ensure resident medical records were secured and held confidential, when during medication administration the nurse walked out of the hall, away from the medication cart, and left laptop computer open, resulting in exposed resident medical information. Findings Included: Upon approaching Licensed Practical Nurse (LPN) F, who was performing medication administration, on 8/02/23 at 7:45 AM, LPN F became very upset, and stated that it was her first day by herself, and she was not comfortable being watched. LPN F stated that she was in the middle of pulling a resident's medications, and was not going to talk to the surveyor until she was done. LPN F stated she could not have someone observing her during medication administration, and also said she was not going to continue. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to; (1. follow physician's orders and to perform a daily pressure ulcer dressing change; and (2. justify use of antipsychotic medication within the standards of practice for two resident (Resident #19 and # 21) from a total sample of 16 residents, resulting in the potential for infection, a wound to degrade and harm to intact skin and potential for unnecessary medication use with the increased potential for serious side effects and adverse reactions, and the inability to monitor the effectiveness of the prescribed treatment due to lack of documented supporting evidence.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of one residents (R19), who had a Foley catheter (tube inserted into the bladder to drain urine), was appropriately assessed for the need to continue or discontinue the use of the catheter, resulting in the potential for complication and/or infections. Findings Include: Resident #19 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R19 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included encephalopathy, urinary retention, history of traumatic brain injury, hypertension (high blood pressure), diabetes mellitus, chronic obstructive pulmonary disease, schizophrenia, anxiety and depression. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to collaborate with and obtain information from the dialysis center related to resident status during and post-dialysis treatment for one (Resident # 356) of one resident reviewed for dialysis, resulting in the potential for unmet post-dialysis care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate monitoring and documentation of psychotropic medications for one residents (R19) reviewed for unnecessary medications, resulting in the potential for unnecessary medication use with the increased potential for serious side effects and adverse reactions, and the inability to monitor the effectiveness of the prescribed treatment due to lack of documented supporting evidence.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medication stored in two of four medication storage rooms were discarded at the time of the expiration date, resulting in the potential for the medications to cause complications and/or not be affective. Findings Included: During an observation on 8/02/2023 at 7:58 AM, with Director of Nursing (DON) B, of the 100 hall kitchen were medications were stored revealed the refrigerator contained 11 boxes of unopened influenza vaccinations that had and expiration date of 6/30/2023. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for two Residents (R21 and R40) of 16 reviewed for medical records, resulting in increased likelihood of medication error or missed treatments and the potential for an inaccurate reflection of resident conditions.

Inspectors wroteThis citation pertains to intake M100138094 Based on observation, interview, and record review, the facility failed to 1) adhere to infection control practices during medication administration observation; and 2) routinely adhere to proper contact precautions for one (Resident # 356) of one resident reviewed for transmission-based precautions, resulting in the potential for cross-contamination, spread of bacteria, and increased risk of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor the antibiotic treatment course for one (Resident # 356) of one resident reviewed for antibiotic use, resulting in the potential for ineffective infection treatment and the return of or worsening of symptoms.