Marysville Care Center

In the surveyor’s words

From the most serious findings on record at Marysville Care Center, in the surveyor’s own words.

• Actual harm, isolatedF760Jul 22, 2025

  Based on interviews, and record review, the facility failed to ensure 1 of 4 sampled residents (Resident 1) reviewed for blood thinning medication (Warfarin) use were free from significant medication errors. Resident 1 experienced harm when they received two doses of a blood thinning medication when the medication was on hold, were hospitalized for a brain hemorrhage (bleeding within the skull), had an INR (International Normalized Ratio - a test to determine how long it takes for blood to clot) of 6.9 (normal range for resident 2.5-3.5) and required Kcentra and Vitamin K (blood clotting medications used for urgent reversal of blood thinner medications) in the emergency room. […]

• Actual harm, isolatedF684Aug 30, 2023

  Based on interview and record review, the facility failed to ensure physician orders and recommendations were followed and a change in condition was identified timely accordance with professional standards of practice for 1 of 3 residents (Resident 1) reviewed for a change in condition. Resident 1 experienced harm when they had a severe increase in edema (swelling caused by excess fluid trapped in body tissues) of all extremities, and developed complications from incorrect application of compression stockings, a lack of monitoring and treating the edema, development of a wound on the right toe related to the increased swelling that required hospitalization for shortness of breath, acute on chronic congestive heart failure (a long-term condition when the heart cannot pump blood well enough… […]

• Actual harm, isolatedF760Aug 30, 2023

  Based on interview and record review the facility failed to administer physician medication orders for 1 of 2 (Resident 1) residents reviewed for medication errors. Failure to clarify a physician's order for a diuretic (medication to reduce fluid buildup in the body) medication resulted in a significant medication error that caused harm to Resident 1 who experienced anasarca (swelling caused by excess fluid trapped in body tissues) of all extremities with a significant increase in lower extremity swelling. Resident 1 required hospitalization for shortness of breath, acute on chronic congestive heart failure (a long-term condition when the heart cannot pump blood well enough as it should) and pleural effusions (buildup of fluid between tissues that line the lungs and chest). […]

• Actual harm, isolatedF686May 10, 2023

  Based on interview and record review, the facility failed to provide necessary treatment and services for 2 of 3 residents (Residents 1, and 3) reviewed for skin and wound cares. The failure to clarify and implement wound care orders, thoroughly assess wounds, change wound dressings when ordered, and to maintain clear and accurate wound documentation placed the residents at risk for deterioration of their wounds and for diminished quality of life. Resident 1 was harmed when they experienced a worsening of their wounds when the facility failed to assess and document the status of their wounds and to implement wound care orders. […]

• Actual harm, isolatedF689May 10, 2023

  Based on observation, interview, and record review, the facility failed to evaluate the need for additional supervision, for 1 of 3 residents (Resident 2) reviewed for accidents and supervision who experienced an injury. Resident 2 experienced multiple falls and according to more than one direct care staff needed one to one supervision; yet this was not assessed. Resident 2 was harmed when they experienced an unwitnessed hip fracture. Findings included . Review of the facility policy titled, Incident and Reportable Event Management, revised date 01/31/2023, showed: The facility to the best of its ability strives to provide an environment that was free from accident hazards over which the facility had control and provided supervision and assistive devices to each resident to prevent… […]