Marwood Manor Nursing Home

In the surveyor’s words

From the most serious findings on record at Marwood Manor Nursing Home, in the surveyor’s own words.

• Actual harm, isolatedF686Jul 30, 2025

  Based on observation, interview, and record review, the facility failed to timely assess and implement interventions to prevent a right heel pressure ulcer for one (R54) of two residents reviewed for skin concerns resulting in the development of a stage three (full thickness tissue loss without visible bone, tendon or muscle) pressure ulcer. Findings include:Review of the facility record for R54 revealed admission into the facility on [DATE] with diagnoses including Status-Post Right Hip Fracture with Surgical Repair, Diabetes Mellitus, and Difficulty in Walking. […]

• Actual harm, isolatedF689Jul 11, 2024

  This citation pertains to Intake: MI00144914. Based on observation, interview, and record review the facility failed to transport a resident safely in a wheelchair for one sampled resident (R42) of eight reviewed for accidents, resulting in a fibula (right lower leg) fracture. Findings include: A review of the intake noted, It was reported the resident was put in a w/c (wheelchair) without foot pegs which resulted in injury. On 7/10/24 at 11:29 AM, R42 was observed sitting in the dining area at a table with other residents. R42 was in a wheelchair with their legs resting on foot pedals. R42's right leg was observed with a gray orthopedic boot. R42 was asked what happened to their leg and was unable to explain due to their cognitive impairment. […]

• Actual harm, isolatedF689Mar 27, 2023

  This citation pertains to Intake: MI00129843. Based on observation, interview and record review, the facility failed to prevent a fall with injury for one sampled resident (R901) of three residents reviewed for falls resulting in the resident experiencing pain and hospitalization . Findings include: A review of Intake MI00129843 revealed the following, Incident Summary: The resident was being assisted by staff to get weighed in [their] bathroom. [R901] was stepping down from the floor scale when [they] lost [their] balance and fell backwards. [R901] landed on bottom. The aide was present with the resident but was unable to intercept the fall. The resident voiced complaints of pain and was transferred to the emergency room to be evaluated. […]

• No harm, potential for more than minimal, widespreadF812May 3, 2023

  Based on observation, interview, and record review, the facility failed to ensure food items were labeled and dated, in the Grand Central kitchen, [NAME] kitchen, Hummingbird kitchen, Dove Lane kitchen, and Bridgeport North kitchen. This deficient practice had the potential to affect all residents that consume food orally. Findings include: On 5/1/23, during an initial tour of the main kitchen and satellite kitchens with Dietary Manager (DM) D, between 9:20 AM-10:45 AM, the following items were observed: Grand Central kitchen: In the Arctic Air refrigerator, there was a resident's container of pasta and chicken that was undated. […]

• No harm, potential for more than minimal, widespreadF812Mar 29, 2022

  Based on observation, interview, and record review, the facility failed to ensure food items were dated when opened and discarded when expired, resulting in the increased potential for foodborne illnesses. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On [DATE] at 9:15 AM during an initial tour of the kitchen with Dietary Staff G and Environmental Services Supervisor B, the following items were observed: In the [NAME] reach-in cooler, there was an opened undated bottle of [NAME] sauce, and 2 opened, undated bottles of barbecue sauce. In addition, the light bulb inside the refrigerator was not functioning. […]