Marianwood Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Marianwood Health and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF689Aug 1, 2024

  Based on observation, interview, and record review, the facility failed to: (1) Ensure water temperatures were maintained to remain within the safe temperature of 110 (+/- 10) degrees Fahrenheit (F) as required for 13 of 13 rooms sampled for hot water temperatures (Rooms 328, 306, 330, 324, 114, 428, 202, 124, 408, 422, 102, 228, & 404); (2) ensure hazardous chemicals were kept locked and secured at all times for 2 of 4 nursing units (Unit A & C); and (3) identify potential risks associated with a resident's care needs and environment to decrease the risk of falling for 1 of 6 residents (Resident 64) reviewed for falls. […]

• Actual harm, isolatedF600Feb 28, 2025

  Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from verbal abuse and mistreatment for 1 of 2 (Residents 1) residents reviewed for resident-to-resident incidents. Resident 1 experienced psychological harm when they had a change in their speaking pattern and tone, flat affect, crying, expressions of re-triggering of prior traumas, and feeling distressed after repeated verbal abuse by their roommate that escalated when not addressed timely by staff. This failed practice placed all residents at risk for the potential of verbal abuse, psychological harm, and diminished quality of life. […]

• Actual harm, isolatedF686Apr 25, 2023

  Based on observation, interview, and record review the facility failed to ensure 1 (Resident 8) of 3 sampled residents reviewed for Pressure Ulcers (PUs) received the necessary treatment and services, consistent with professional standards of practice, to promote healing, and prevent new ulcers from developing. Failure of the facility to assess skin integrity, follow Care Plan (CP) Interventions and initiate treatment orders caused harm to Resident 8 who developed an avoidable facility acquired right rib PU and a reopened a tailbone PU. Failure of the facility to complete skin assessments, prevent and treat PUs, placed Resident 8 and all other residents at risk for pressure ulcer development, increased risk for infection, and diminished quality of life. […]

• No harm, potential for more than minimal, widespreadF725Aug 1, 2024

  Based on observations, interview, and record review, the facility failed to ensure sufficient qualified nursing staff were available to provide care and services for all facility residents including assistance with Activities of Daily Living (ADL) and timliness of call light response in accordance with established clinical standards, Care Plan (CP), and resident preferences. These failures placed residents at risk for unmet care needs and a diminished quality of life. Findings included . <Resident Council (RC)> Review of the 01/24/2024 RC meeting notes showed residents reported poor response times. […]

• No harm, potential for more than minimal, widespreadF812Aug 1, 2024

  Based on observation, interview, and record review, the facility failed to ensure resident meals were stored, prepared, and served in a sanitary manner for 1 of 1 kitchens and 1 of 4 unit pantries (Unit 400). These failures left residents at risk for spoiled or contaminated foods, and food-borne illness. Findings included . <Facility Policy> According to the facility's 07/2024 Food Storage policy all food items would be labeled with with a manufacturer's expiration date or the date of receipt. The policy showed refrigerated foods would be discarded using either the manufacturer's expiration date or seven days after the written date. The policy showed all refrigerators used for nutrition would be cleaned weekly by dietary staff. […]