Marlette Community Hospital LTCU

In the surveyor’s words

From the most serious findings on record at Marlette Community Hospital LTCU, in the surveyor’s own words.

• Immediate jeopardy, widespreadF678Apr 18, 2022

  Based on observation, interview and record review, the facility failed to 1) Ensure that staff are trained and have available telephone numbers and a process to call a Code Blue/Rapid Response to summon an emergency response team and 2) Ensure the availability and viability of emergency medical equipment (crash cart) to be able to provide basic life support prior to the arrival of emergency medical personnel, in the event of a medical emergency, resulting in Immediate Jeopardy for all 26 residents being placed in a state of immediate - threat of harm, injury, and/or death, related to a lack of emergency equipment. Immediate Jeopardy: The Immediate Jeopardy began [DATE]. The Immediate Jeopardy was identified on [DATE]. […]

• No harm, potential for more than minimal, widespreadF812Aug 7, 2025

  Based on observation, interview and record review, the facility failed to ensure food was properly labeled, dated and stored to maintain best practices resulting in the potential to spread food borne illness to all residents that consume food from the kitchen.Findings include:On 8/5/25 at 9:00 AM, observations and interview during Initial kitchen include: On the prep table there was a large plastic container with an open blue bag in it, the container had no label, no open or expiration date on it. During interview with dietary supervisor “C”, when asked what the product was, Dietary Supervisor C stated it was rice, and acknowledged there is no dates or label present, but reports “there should be”. […]

• No harm, potential for more than minimal, widespreadF880Aug 7, 2025

  Based on interview and record review the facility failed to maintain a comprehensive infection control program, resulting in the facility not mapping infections or completing audits and the potential for infection clusters to go unnoticed. Findings include: DPS 2 Based on interview and record review, the facility failed to have an active 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 water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all of the residents in the facility. Findings include:On 08/07/2025 at 1:13PM, an interview was conducted with the Director of Nursing (DON). […]

• No harm, potential for more than minimal, widespreadF812Aug 14, 2024

  Based on observation, interview, and record review, the facility failed to date mark potentially hazardous foods, maintain sanitary equipment, and maintain proper glove use and handwashing, resulting in an increased risk of foodborne illness, affecting all residents that consume food from the kitchen. Findings include: On 8/12/24 at 11:40 AM, during a kitchen inspection, assisted by Certified Dietary Manager (CDM) H, an opened bag of hard boiled eggs was observed to not be provided with a date mark to identify the discard date. On 8/12/24 at 11:45 AM, a chicken wrap, located in the reach-in deli cooler, was observed to not be provided with a date mark. At this time, CDM H stated the wrap was left over from the day before. […]

• No harm, potential for more than minimal, widespreadF576Jul 26, 2023

  Based on interview and record review, the facility failed to ensure that 27 out of 27 residents received their mail on Saturdays, resulting in residents not being able to exercise their right to receive mail and access communication. Findings Include: On 7/20/23 at 1:30 PM, during a meeting with a Confidential Group of Residents, they were asked if they received mail on Saturdays. The group replied, No, we don't. With further discussion, the residents said it was something they had recently been talking about, because they were not receiving their mail on Saturdays. During an interview with the Activities Director F, on 7/20/2023 at 2:30 PM, she was asked if the resident's received mail on Saturdays and she said they did not. […]