Marshall Rehab & Nursing

In the surveyor’s words

From the most serious findings on record at Marshall Rehab & Nursing, in the surveyor’s own words.

• Actual harm, isolatedF697Apr 30, 2024

  Based on interview and record review the facility failed to identify the root cause of pain for one resident (R1) of three residents reviewed for pain in a sample of three residents. This failure resulted in (R1) experiencing continued pain requiring narcotic pain medications. Findings Include: R1's Care Plan updated 3/13/24 includes the following diagnoses: Fractured Neck of Right Femur with open Reduction and Internal Fixation, Right Hip Pain, Dementia, Osteoarthritis, Contusion of the Wall of the Thorax, Weakness, Insomnia, and Depression. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is severely cognitively impaired. […]

• Actual harm, isolatedF689Sep 29, 2021

  Based on observation, interview and record review the facility failed to properly restrain (R1) during a transport in the facility van. This failure caused (R1) to be thrown from the chair and sustain a compression fracture of the first lumbar vertebrae. R1 is one of three residents reviewed for injuries in a sample list of six. Findings Include: R1's Diagnoses report dated 9/29/21 includes the diagnoses: Difficulty Walking and Acquired absence of Right Leg below the knee. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. […]

• Actual harm, isolatedF689May 14, 2021

  Based on interview and record review, the facility failed to develop, implement, and provide timely interventions resulting in repeat falls for a resident. This failure affects one resident (R13) of five residents reviewed for falls in the sample list of 29. R13 fell , requiring medical intervention resulting in a scalp laceration with 8 sutures. Findings include: R13's undated Face Sheet documents R13's diagnoses as: Difficulty in Walking, History of Falling, Repeated Falls, Age Related Physical Debility, Shortness of Breath. R13's Minimum Data Set (MDS) dated [DATE], documents R13 requires extensive assistance with transferring and toileting, can only stabilize self with staff assistance when moving, walking, turning around, moving on and off toilet, and surface to surface transfers. […]

• No harm, potential for more than minimal, widespreadF921Jun 12, 2026

  Based on observation, interview, and record review the facility failed to provide and maintain a safe, functional, sanitary and comfortable environment. This failure has the potential to affect all 53 residents residing in the facility. Findings Include: The Environmental Services Homelike Environment policy dated 12/27/23 documents the facility supports the residents to live in a homelike environment. Housekeeping and maintenance services are necessary to maintain a sanitary, orderly, and comfortable interior. The Resident Rights Policy and Procedure dated 2026 documents each resident has the right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. […]

• No harm, potential for more than minimal, widespreadF804Feb 25, 2026

  Based on observation, interview and record review the facility failed to ensure resident meals are palatable. This failure has the potential to affect all 58 residents residing in the facility.Finding include:The Facility Daily Midnight Census documents 58 residents reside in the facility.The Facility Grievance concern dated 12/1/25 documents the food was 'cold'. On 2/24/26 at 1:00 PM, Resident meal trays were sitting in the main dining room with more than half of the food left on each of twelve trays.On 2/25/26 at 12:55 PM, Resident meal trays were sitting in the main dining room with more than half of the food left on each of fifteen trays.On 2/25/26 at 1:15 PM, the facility provided a test tray. […]