Heritage House of Marshall Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Heritage House of Marshall Health & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Jun 26, 2024

  Based on observation, interview, and record review, the facility did not ensure treatment and services was provided, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing for 1 of 4 residents reviewed for quality of care. (Resident #38) 1. The facility failed to appropriately assess Resident #38's skin and wounds after readmission from 06/20/24 through 06/23/24. A new wound to the right lateral glute was identified by the facility on 06/24/24 when it was a Stage III pressure injury (a full thickness loss of skin extending to the subcutaneous tissue). 2. […]

• Immediate jeopardy, isolatedF580Feb 15, 2023

  Based on interview and record review the facility failed to immediately consult with the resident's physician when there was significant change in the resident's physical, mental, or psychosocial status for 2 of 7 residents reviewed for notification of changes. (Resident #1 and #3) The facility failed to notify the resident's physician when resident #1 stopped eating or taking medications for about 10 days. The facility failed to notify the resident's physician when Resident #1 and #2 developed pressure sores. An Immediate Jeopardy (IJ) situation was identified on 02/10/23 at 4:14 p.m. […]

• Immediate jeopardy, isolatedF600Feb 15, 2023

  Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free from neglect for 2 of 7 residents reviewed for neglect ( Resident #1 and Resident #3). The facility had system failures in that they failed to: 1. Ensure Resident #1 had nutritional interventions in place such as a way to provide nutrition. 2. Ensure Resident #1 had pressure sore interventions in place such as physician notification and treatment of the wounds. 3. Ensure Resident #3 had interventions in place to prevent the development and worsening of pressure sores. 4. Ensure care plans were developed, in place and implemented for Resident #1 and Resident #3's needs. 5. […]

• Immediate jeopardy, isolatedF656Feb 15, 2023

  Based on 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 2 of 4 residents reviewed for care plans (Resident #1, Resident #3) Resident #1 had overall ADL decline due to poor nutrition, weight loss and pressure sores with no care plan interventions in place, and she was hospitalized . Resident #3 had a pressure sore that was not treated and caused an overall decline and hospitalization with no care plan interventions in place. The facility was cited for failure to develop and implement a comprehensive person-centered care plan on 08/17/22 during their annual survey. They were also cited on 12/07/22. […]

• Immediate jeopardy, isolatedF686Feb 15, 2023

  Based on interview and record review based on the comprehensive assessment the facility failed to ensure residents received care consistent with professional standards of practice to promote healing and prevent infection and new pressure sores from developing for 2 of 5 residents reviewed for pressure sores. (Resident #1 and Resident #3) 1. The facility failed to notify the physician of the pressure sores for Resident #1 and Resident #3 2. The facility failed to obtain treatment orders for treatment wounds for Resident #1 and Resident #3 3. The facility failed to ensure the dietician was notified, and the resident receive nutritional interventions Resident #1 and Resident #3 4. They failed to ensure the Wound Care Doctor recommendations were followed for Resident #3 5. […]