Marshall Health Care And Rehab

In the surveyor’s words

From the most serious findings on record at Marshall Health Care And Rehab, in the surveyor’s own words.

• Immediate jeopardy, patternF600Apr 20, 2022

  Based on review of the facility's initial report and investigation summary, observations of both an audio and video recording, and photographs, the facility failed to protect three residents from mental abuse and extreme humiliation perpetuated by Certified Nursing Assistant (CNA) #1 for 3 of 3 residents sampled for abuse (Resident #3, #2, and #1). CNA #1 posted, on social media, two photographs of residents not groomed appropriately and with an insulting statement captioned on one of the photographs, an audio recording with CNA #1 making insulting remarks while care was being provided to the resident who can be heard sobbing and calling CNA #1 names, and a short video of a resident who was talking to him/herself while eating. […]

• Actual harm, patternF550Apr 20, 2022

  Based on interviews, review of recordings and photos, and review of the facility reportable incident, the facility failed to protect and promote resident dignity when photos, audio recording, and video recording were shared with members of the public by a Certified Nursing Assistant (CNA) #1. A reasonable and prudent person would be distraught that his/her dignity was violated and would suffer from embarrassment for 3 of 3 residents sampled for abuse (Resident #3, #2, and #1). Findings: On 4/19/22 at 11:30 a.m., the Administrator shared with a surveyor, two photos, an audio recording and a video recording taken by CNA #1 that was shared with members of the community. […]

• Actual harm, patternF583Apr 20, 2022

  Based on review of the facility's report and investigation, photos and recordings review, policy reviews, and interviews, the facility failed to ensure residents' rights to privacy and confidentiality were not violated when unauthorized video recording, audio recording, and photographs taken by a Certified Nursing Assistant (CNA) and shared on social media for 3 of 3 residents reviewed for abuse (Resident #3, #2, and #1). A reasonable and prudent person would be distraught and embarrassed and would suffer from anger and deep sadness due to lack of control over the situation. […]

• Actual harm, isolatedF684Jun 26, 2025

  Based on record review and interviews, the facility failed to monitor and adequately treat 1 of 2 residents (Resident #255 [R255]) reviewed for Skin Conditions, when the facility failed to follow discharge orders for the use of a diuretic medication (a medication used to treat fluid retention [edema] associated with conditions such as heart failure), obtain and monitor daily weights, and failed to report a potentially significant weight gain. These failures resulted in harm to R255 who required hospitalization for the treatment of worsening signs and symptoms of diastolic congestive heart failure. […]

• No harm, potential for more than minimal, patternF711Jun 26, 2025

  Based on record reviews and interviews, the facility failed to ensure the physician reviewed the resident's total program of care, ensure orders were complete, signed and dated for 2 of 4 residents reviewed under the general pathway (Resident #6 [R6] and [R255]). Findings: 1. On 12/27/24, a telephone order for R6 indicated, Update loperamide [a diarrhea medication] order to recommended dosage. This order was incomplete, signed by the provider, but not dated by the provider. A second telephone order indicated Give ½ of Resource juice [with (w/)] meds [twice a day (BID)]. The provider signed but did not date the order. On 6/26/25 at 9:18 a.m., during an interview with a surveyor and the Director of Nursing (DON), R6's medical record was reviewed. […]