Marshall Nursing and Rehabilitation Community

In the surveyor’s words

From the most serious findings on record at Marshall Nursing and Rehabilitation Community, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Oct 11, 2023

  This citation pertains to intake MI00137735 and MI00137656 Based on interview and record review, the facility failed to 1) ensure the emergency Ambu-bag was at the bedside 2) failed to provide timely cardio-pulmonary resuscitation (CPR) according to standards of practice for one (Resident #3) of one reviewed for emergency resuscitation, resulting in an Immediate Jeopardy when R3 was discovered unresponsive without pulse or respirations with a full 3 minute delay prior to the initiation of CPR resulting in death and 3) failed to ensure current Cardio-pulmonary Resuscitation (CPR) certification for 3 licensed nursing staff (received online training only) resulting in the potential for the 32 facility residents who are Full-Code to not being resuscitated during a cardiopulmonary arrest. […]

• Actual harm, isolatedF686Sep 20, 2024

  Based on observation, interview, and record review, the facility failed to prevent the development of pressure injuries, including a medical device-related pressure injury, for one resident (Resident #26) out of 4 reviewed for pressure injuries. This deficient practice resulted in resident experiencing harm due to facility-acquired pressure injuries. Findings include: Resident 26 (R26) A review of the medical record indicated that R26 was admitted to the facility on [DATE] with diagnoses including sepsis, osteomyelitis, a sacral pressure ulcer, muscle weakness, and type 2 diabetes. […]

• Actual harm, isolatedF697Sep 20, 2024

  Based on observation, interview, and record review the facility failed to ensure pain medications were given as ordered for one (resident #26) of two reviewed for pain, resulting in resident experiencing harm with uncontrolled pain. Findings include: Resident 26 (R26) A review of the medical record indicated that R26 was admitted to the facility on [DATE] with diagnoses including sepsis, osteomyelitis, a Stage 4 sacral pressure ulcer (full thickness skin loss that extends into muscle, bone or supporting structures) , muscle weakness, and type 2 diabetes. […]

• Actual harm, isolatedF684Apr 26, 2021

  Based on observation, interview and record review, the facility failed to provide quality of care for 6 of 8 residents (#10, 15, 35, 46, 51 and 302), resulting in lack of wound assessments for Resident #302, failure to identify residents during medication administration (R10, 15, 35 and 46) and failure to monitor, assess, treat, hospitalize and provide comfort measures resulting in death for Resident #51. Findings include: Resident #51 According to the clinical records, including the Minimum Data Set (MDS) dated [DATE], Resident 51 (R51) was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Brief Interview for Mental Status (BIMS) reflected R51 scored 15 out of 15 (cognitively intact). […]

• No harm, potential for more than minimal, widespreadF812Sep 8, 2025

  Based on observation, interview and record review the facility failed to maintain best practices in accordance with professional standards of food service safety. The deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen.Findings include: 09/02/2025 at 9:27AM, observation of a beverage pitcher found brown and white dried liquids on it. The pitcher was stored with other pitchers and storage containers on a shelf under the prep table. Certified Food Manager (CFM) BB confirmed that this area was where cleaned ready to use containers were stored. On 9/2/25 at 10:33 AM, observation of the kitchen ice scoop holder found an increased accumulation of white and brown crusted debris at the bottom inside of the holder. […]