Marshall Nursing and Rehabilitation Community
575 N Madison Street
Marshall, MI, 49068
2697814281
CCN: 235174
1
Overall1
Health2
Staffing2
QualitySpecial FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
Ownership
| Name | Role | % |
|---|---|---|
| ATRIUM CENTERS, INC. | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% |
| AMICUS CAPITAL HOLDINGS INC ESOP | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED |
| BAILEY, ESSEL | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED |
| FINNEY, DONALD | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED |
| PAREDES, MIGUEL | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED |
| LUMENT REAL ESTATE CAPITAL LLC | 5% OR GREATER MORTGAGE INTEREST | NOT APPLICABLE |
| FINNEY, DONALD | CORPORATE DIRECTOR | NOT APPLICABLE |
| LOCKHART, DENNIS | CORPORATE DIRECTOR | NOT APPLICABLE |
| BAILEY, ESSEL | CORPORATE DIRECTOR | NOT APPLICABLE |
| ANDERSON, CURT | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| BROWNE, ERIKA | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| CHERRY, JILL | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| GARDNER, LESLIE | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| HENDERSHOT, NEIL | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| ISRAEL, ROBERT | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| JOHNSON, CINDY | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| LA ROCCO, CHRISSIE | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| ATRIUM CENTERS MANAGEMENT LLC | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| AMICUS CAPITAL HOLDINGS INC ESOP | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| ATRIUM CENTERS, INC. | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| ALBRIGHT ROSS, SUSAN | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
Penalties (4)
| Date | Type | Amount |
|---|---|---|
| 2024-08-30 | Fine | $52K |
| 2024-08-30 | Payment Denial | 33 days |
| 2023-10-11 | Fine | $54K |
| 2023-10-11 | Payment Denial | 22 days |
Health Deficiencies (72)
2025-09-08 · Health
E
F921 · Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
D
F887 · Infection Control Deficiencies
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
D
F883 · Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
F
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
E
F865 · Administration Deficiencies
Have a plan that describes the process for conducting QAPI and QAA activities.
F
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F791 · Quality of Life and Care Deficiencies
Provide or obtain dental services for each resident.
D
F761 · Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
E
F756 · Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
D
F686 · Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
D
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
E
F680 · Quality of Life and Care Deficiencies
Ensure the activities program is directed by a qualified professional.
E
F679 · Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
D
F677 · Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
D
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
D
F637 · Resident Assessment and Care Planning Deficiencies
Assess the resident when there is a significant change in condition
D
F628 · Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
D
F578 · Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
2025-08-20 · Health
D
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
2025-05-29 · Health
D
F761 · Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
D
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
2025-02-12 · Health
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
F
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
2024-09-20 · Health
F
F921 · Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
E
F867 · Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
D
F849 · Administration Deficiencies
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
F
F814 · Nutrition and Dietary Deficiencies
Dispose of garbage and refuse properly.
F
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F806 · Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
E
F804 · Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
E
F761 · Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
D
F759 · Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
D
F700 · Quality of Life and Care Deficiencies
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
D
F698 · Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
G
F697 · Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
D
F695 · Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
D
F692 · Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
D
F688 · Quality of Life and Care Deficiencies
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
G
F686 · Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
D
F655 · Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
D
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
F
F623 · Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
D
F584 · Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
2024-08-30 · Health
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
2024-05-24 · Health
D
F949 · Administration Deficiencies
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
D
F947 · Nursing and Physician Services Deficiencies
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
D
F940 · Administration Deficiencies
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
D
F730 · Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
E
F726 · Nursing and Physician Services Deficiencies
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
D
F676 · Quality of Life and Care Deficiencies
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
F
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
2024-03-14 · Health
D
F686 · Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
D
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
D
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
D
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
2023-10-11 · Health
E
F921 · Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
F
F725 · Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
D
F695 · Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
D
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
J
F678 · Quality of Life and Care Deficiencies
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
2023-08-02 · Health
D
F881 · Infection Control Deficiencies
Implement a program that monitors antibiotic use.
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F842 · Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F761 · Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
D
F758 · Pharmacy Service Deficiencies
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
D
F698 · Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
D
F690 · Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
D
F658 · Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
D
F583 · Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
2023-04-05 · Health
D
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
D
F655 · Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day3.68
3.75
RN Hrs/Resident/Day0.54
0.64
LPN Hrs/Resident/Day0.81
1.09
CNA Hrs/Resident/Day2.33
2.02
PT Hrs/Resident/Day0.12
0.03
Data as of 2026-03-01