Marlora Post Acute Rehab Hosp

In the surveyor’s words

From the most serious findings on record at Marlora Post Acute Rehab Hosp, in the surveyor’s own words.

• Immediate jeopardy, patternF760Dec 6, 2024

  Based on interview and record review the facility failed to ensure four out of eight sampled residents (Resident 6, Resident 26, Resident 29, and Resident 30) were free of a significant medication error. The facility failed to: 1. Ensure the licensed nurses checked Resident 6's heart rate prior to administering Amiodarone on as ordered 13 times from 10/1/2024 to 10/31/2024, and 13 times from 11/1/2024-11/20/2024. 2. Ensure Resident 26's Mexiletine (medication for the treatment of life-threatening heart disease including ventricular arrhythmias [an irregular heartbeat], such as sustained ventricular tachycardia [a rapid, irregular heartbeat], a life-threatening arrhythmia [an irregular heartbeat) 150 milligrams ([mg] a unit of weight measurement) was administered every eight hours as… […]

• Immediate jeopardy, isolatedF605Nov 23, 2025

  Based on interview and record review, the facility failed to ensure a resident, who had diagnoses of congestive heart failure ([CHF] a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), chronic obstructive pulmonary disease with acute exacerbation ([COPD] a chronic lung disease causing difficulty in breathing), chronic respiratory failure (a long-term condition where the lungs cannot supply enough oxygen to the blood or remove enough carbon dioxide) and dependence on supplemental oxygen (O2) was not administered a narcotic (a substance used to treat moderate to severe pain by binding to opioid receptors in the central nervous system)-analgesic (a drug or agent used to relieve pain, acting as a painkiller);… […]

• Actual harm, isolatedF600Aug 18, 2021

  Based on interview, and record review, the facility failed to ensure residents were free from rough handling for one of three residents (Resident 1). Certified Nursing Assistant 1 (CNA 1) was observed by CNAs 2 and 3 firmly holding Resident 1's face with a soiled rubber glove while providing care to Resident 1. This deficient practice violated Resident 1's rights and resulted in disrespect and had a high risk for mental anguish. Findings: During a review of Resident 1's Admission Record (Face Sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF865Dec 6, 2024

  Based on interview and record review, the facility's Quality Assessment and Assurance committee ([QAA] a group of facility staff who identifies, evaluates, and implements measures to improve the quality care and life for the residents in the facility) and Quality Assurance Performance Improvement ([QAPI] a group who takes a systemic, interdisciplinary, comprehensive, and data driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) committee failed to identify concerns related to significant medication errors (a preventable event that jeopardizes a patient's health and safety) in the facility. […]

• No harm, potential for more than minimal, widespreadF941Dec 6, 2024

  Based on interview and record review the facility failed to ensure two out of two sampled staff, Licensed Vocational Nurse (LVN) 2 and 3, received mandatory training of effective communications upon hire. This failure had the potential to result in staff with poor communication skills and may negatively affect the residents' quality of care. Findings: During an interview and record review on 12/6/2024 at 11:50 a.m. with the Director of Staff Development (DSD), LVN 2 and 3's personnel records were reviewed, and the orientation training indicated no documented evidence effective communication was taught to LVN 2 and 3. […]