Marlborough Hills Rehabilitation & Health Care Cen

In the surveyor’s words

From the most serious findings on record at Marlborough Hills Rehabilitation & Health Care Cen, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 11, 2025

  Based on record review, observations and interview, the facility failed to provide a safe smoking environment for one Resident (#14), of 5 applicable residents, out of a total sample of 34 residents. Specifically, for Resident #14, the facility failed to: -ensure that oxygen was not in use by the Resident when a cigarette placed in the Resident's mouth was lit by staff during a supervised smoking session in the designated smoking area where eight other residents were also present. -ensure that the Resident's oxygen tank and oxygen equipment was prohibited from the designated smoking area. […]

• Actual harm, isolatedF686Mar 11, 2025

  Based on observation, interview, and record review, the facility failed to provide care consistent with professional standards of practice to prevent and treat a pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) and prevent further skin and pressure injury for one Resident (#43) out of a total sample of 34 residents. Specifically, for Resident #43, the facility staff failed to: -obtain a Physician's order for the appropriate application, removal, and monitoring of a Controlled Ankle Motion (CAM: orthopedic medical device used for the treatment of severe sprains, fractures in the ankle or foot) boot when the Resident was identified as being at risk for developing pressure ulcers. […]

• Actual harm, isolatedF658Mar 24, 2022

  Based on records reviewed and interviews for one of four sampled residents (Resident #4), who had a surgical wound to his/her her right lower extremity, the Facility failed to ensure that nursing provided care in accordance with professional standards of practice, when dressings to his/her wound were not completed as ordered, physicians orders for the pressure settings for the wound vac (vacuum assisted closure) machine were not obtained, weekly wound care assessments were not completed, as a result Resident #4 was transferred and admitted to the Hospital, due to a surgical wound infection. Findings include: Review of Facility's Policy titled, Weekly Body Audit, dated 07/2017, indicated that staff are required to complete a skin check evaluation weekly. […]

• Actual harm, isolatedF686Jan 6, 2022

  Based on observation, record review, and interview the facility failed to provide pressure relief to prevent a pressure ulcer from worsening for one Resident (#98) out of four applicable sampled residents, in a total sample of 34 residents. Findings include: Review of the facility's policy for Prevention and Management of Pressure Injuries, dated July 2017, indicated the following: -Policy: Residents with pressure injuries and those at risk for skin breakdown are identified, assessed and provided appropriate treatment to encourage healing and/or maintenance of skin integrity. […]

• Actual harm, isolatedF692Jan 6, 2022

  Based on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status and track the resident's weight leading to a significant weight loss for one resident (#95), in a total sample of 34 residents. Findings include: Resident #95 was admitted to the facility in 10/2021. Review of the facility policy for weights indicated the following: -The following residents are weighed weekly X4 Newly admitted residents Newly readmitted residents Residents with an unplanned weight loss of >5% in a month All weight loss/gain of 5 pounds or more on a resident weighing over 100 pounds requires a reweigh for verification, on the same scale with a nurse present. […]