Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Goldwater Care Marseilles during CMS and state inspections, most recent first.
Failure to Identify and Accurately Document Pressure Injuries: The facility did not identify a resident’s heel pressure injury until it had progressed to a Stage 3, despite the resident being at risk and having weekly skin checks with no foot concerns documented shortly before the wound was first assessed. The resident’s record lacked wound progress notes, and staff observations later noted dark tissue and maceration at the heel. The facility also failed to accurately document weekly wound assessments for a second resident with pressure injuries, as the wound record repeated identical findings across multiple weeks and differed from a specialty wound evaluation; staff stated the wound assessments were kept in a separate program and were not part of the medical record.
Menu Not Followed and Posted Meal Items Did Not Match Served Food: A resident was served fish sticks and other items that did not match the meal ticket, and other residents in the dining room received the same substituted foods. The posted lunch menu also did not match the facility’s written menu, and the Dietary Mgr stated several items were unavailable because they were not ordered or were forgotten, while fish sticks were routinely used instead of the planned fish entrée.
Staffing was insufficient to meet resident needs, with staff reporting fewer CNAs and nurses than the facility assessment estimated, frequent agency use, and difficulty answering call lights, completing showers, and giving breaks. Staff described managing resident groups with only 1 nurse and 2-3 CNAs, and residents reported delayed call light response and missed showers, including one resident who said she had only been getting one shower a week because of the staffing shortage.
A resident’s room door did not close properly because the bed had to be pushed toward the wall to allow the door to shut, and the bed caught on the door when reopened. A CNA said a protruding object at the head of the bed prevented the bed from being placed directly against the wall. The resident had impaired mobility, impaired vision, and dependence on staff for ADLs, with diagnoses including DM2 with diabetic neuropathy, muscle wasting and atrophy, and lack of coordination.
A resident’s venous stasis wound was not accurately assessed on a weekly basis, with repeated wound documentation that did not match the wound specialist’s findings or the observed condition. In addition, one resident’s ordered breast biopsy was never scheduled, and another resident’s dermatology visits for painful skin tags were cancelled twice, including one cancellation due to lack of transportation when the van driver called off.
A resident with diabetes, a right breast lump, and morbid obesity fell during a mechanical lift transfer and was found on the floor with the lift still attached. The RN said the resident fell during the transfer, and the DON’s investigation found the lift base was not opened wide enough to ensure proper balance. The resident was sent to the hospital, where imaging was negative, and was discharged back to the facility in stable condition.
The facility failed to honor meal preferences and lactose-free diet orders for two residents. One resident who reported lactose intolerance was served pudding and mashed potatoes, and the Dietary Manager confirmed the pudding contained dairy and that mashed potatoes may be prepared with milk. Another resident's meal ticket listed no fish and lactose intolerance, yet the ticket also showed fish and red beans and rice, and the meal was changed to mashed potatoes when beans were not ordered. Records showed both residents had lactose-free orders, and one care plan directed staff to obtain and honor food preferences.
A resident with a dehisced surgical wound on the right ankle and a history of recurrent infections did not receive daily dressing changes as ordered, particularly on weekends, despite EMR and TAR entries indicating that wound care was completed. The resident and her daughter reported that dressings were not changed daily and that the wound worsened when care lapsed, while the ADON/wound nurse acknowledged prior issues with staff not changing dressings and confirmed the wound required daily treatment. The care plan and facility skin policy required treatment as ordered and daily licensed nurse observation and documentation of the wound, but surveyors observed an outdated dressing and discrepancies between the documented dressing change date and the date written on the dressing itself.
Three residents experienced unauthorized and undocumented withdrawals from their trust fund accounts, with large sums removed without proper witness signatures or receipts. One resident with severe cognitive impairment had minimal belongings despite significant withdrawals, while two cognitively intact residents had funds withdrawn without their or their representatives' authorization. The staff member responsible was terminated after submitting forged medical documentation, and the police were notified.
A resident with a stage 2 pressure injury experienced worsening wound size and drainage while in the facility. Despite ongoing assessments by the wound nurse, the physician was not notified of the lack of improvement, and the nurse practitioner was unaware that the wound doctor was not following the case. Facility policy requiring physician notification for lack of response to treatment was not followed.
A resident with diabetes and a left heel ulcer did not receive a prescribed antibiotic ointment for nine days due to a delay in entering the order into the EMR, and staff failed to promptly notify a physician when the wound worsened, resulting in delayed assessment and treatment despite clear changes in wound size and condition.
A resident with a metastatic brain neoplasm was not adequately supervised, leading to an incident where they threw a chair at another resident, causing a knee fracture. The injured resident required hospitalization and ongoing pain management, with pain levels documented between 4/10 and 8/10. The facility's DON and Administrator confirmed the incident and the resulting hospitalization.
A resident sustained a nondisplaced fracture of the left patella when the facility van, driven by the Dietary Manager instead of the regular driver, collided with a parking garage clearance sign. The resident, seated in a wheelchair, slid forward during the incident. The Dietary Manager had not completed a comprehensive safety course, contributing to the accident.
A resident with severe cognitive impairment was subjected to inappropriate sexual behavior by another resident with dementia. The incident was witnessed by a physical therapist who intervened immediately. The second resident was confused and later expressed regret. The facility's video footage was unavailable for review, and the facility's policy prohibits such abuse.
The facility failed to report and investigate multiple allegations of theft involving residents' money and property. Despite the facility's policy requiring immediate reporting of such incidents, several staff members did not ensure reports reached the administrator or were documented. Residents reported missing money, gift cards, and personal items, but these incidents were not properly documented or investigated, and local law enforcement was not notified.
The facility failed to administer medications per physician's orders and policy, leading to significant errors. An LPN pre-filled medicine cups against policy, and multiple residents reported late or incorrect medication administration, affecting their health. The DON and administrator acknowledged these issues but did not document them as errors.
A resident with Parkinson's Disease was administered Carbidopa-Levodopa incorrectly due to a transcription error in the MAR. The resident's orders specified a different dosage and frequency than what was documented and administered. The error was identified by a Nurse Practitioner, who then informed a Registered Nurse to correct the order.
The facility failed to ensure resident dignity by not knocking before entering a room and did not respond to call lights in a timely manner. A staff member entered a resident's room without knocking, and several residents reported long wait times for assistance after activating call lights, with some waiting up to 45 minutes. The facility's administrator acknowledged that the response times were not acceptable.
A resident with a history of chronic conditions experienced severe chest pain, which was not immediately reported to a medical doctor by the facility staff. The resident informed a nurse, who administered Alprazolam but did not notify a doctor. The night nurse later called 911 when the doctor did not respond, and the resident was taken to the hospital, where the pain was attributed to anxiety. The facility's policy requires staff to notify a doctor in such cases, which was not followed.
A facility failed to develop a care plan for a resident's hand braces, which were used to prevent contractures. The resident was observed with lamb skin braces, but the care plan did not document their use. A nurse confirmed the braces were for prevention, and the DON was unaware of their inclusion in the care plan.
Two residents in the facility did not receive proper ADL care, including nail cleaning and shaving, as per the facility's policies. One resident, who requires assistance due to cognitive and physical limitations, had overgrown facial hair and dirty fingernails, while another resident with dementia and blindness had unclean nails despite daily care requirements. Staff acknowledged the lapses in care.
A resident's oxygen equipment was not changed or dated weekly as per facility policy, and an oxygen cylinder tank was found unsecured. The resident reported that the night shift nurse was supposed to change the tubing weekly, but it had not been done. The DON confirmed the procedures were not followed, leading to the deficiency.
A resident's medications were left at the bedside without a physician's order for self-administration. An RN left Lanthanum and Midodrine pills on the resident's bedside table, contrary to facility policy requiring observation to ensure ingestion. The facility's EHR lacked documentation for self-administration, and staff interviews confirmed the absence of necessary orders and assessments.
A facility failed to follow a physician's order to send a resident to the hospital, resulting in delayed treatment and the resident's admission to the ICU with multiple comorbidities. The resident exhibited significant symptoms, but the facility's DON and nursing staff did not act on the order, leading to a continued decline in the resident's condition.
The facility failed to follow its dialysis policy and procedures for six residents, resulting in inadequate monitoring and documentation of dialysis care. The facility did not consistently document or perform required checks, including vital signs, access site inspections, and post-treatment assessments, potentially putting residents at risk for complications.
Failure to Identify and Accurately Document Pressure Injuries
Penalty
Summary
The facility failed to identify a pressure injury on a resident’s left heel until it was already a Stage 3. The resident had diagnoses including acute and chronic respiratory failure, morbid obesity, type 2 diabetes mellitus, and chronic kidney disease, and her Braden Scale score of 17 indicated she was at risk for developing a pressure injury. Her weekly skin assessments showed a gap in documentation, with no skin assessments recorded between an earlier assessment and the one completed on 4/15/26, which documented no foot concerns. The wound summary later showed the first assessment of the left heel on 4/18/26 as a Stage 3 with intact skin, deep maroon tissue, and necrotic soft adherent tissue measuring 4 x 2 x 0 cm. The resident’s EMR contained no progress notes related to the wound. On 5/8/26, a nurse removed the old dressing from the left heel and observed maceration around the edges with dark tissue in the middle, then cleansed the area and applied calcium alginate and a bordered foam dressing with a heel lift boot. The resident’s care plan dated 4/17/26 stated there was an open area to the left heel related to immobility, decreased awareness due to disease process, chronic respiratory failure, and history of ulcers. The facility policy stated that residents at risk would have weekly skin assessments by a licensed nurse, daily skin observation during cares and bath days by the CNA, prompt reporting of changes to the charge nurse, and weekly measurement and recording of pressure injuries. The facility also failed to complete accurate weekly wound assessments for a second resident with pressure injuries. That resident had diagnoses including chronic venous hypertension with ulcer of the left lower extremity, chronic pain syndrome, pressure ulcer of the right upper back, and spastic hemiplegia affecting the left nondominant side. A handwritten document identified a left ankle Stage 2 and a right back pressure injury, but the wound summary report showed identical assessments repeated across multiple dates for a facility-acquired Stage 4 pressure injury, including the same size, tissue description, and scant serosanguineous exudate. A specialty wound evaluation dated 5/5/26 described the right upper back wound differently, including a smaller size and different tissue characteristics. Staff stated the wound assessments were in a separate program, that the DON and ADON had access to it, and that the assessments were not part of the medical record. The facility policy stated that pressure and other ulcers would be assessed and measured at least every seven days by a licensed nurse and documented in the resident’s clinical record.
Menu Not Followed and Posted Meal Items Did Not Match Served Food
Penalty
Summary
The facility failed to ensure the posted and served lunch menu was followed. On 5/8/26 at 11:59 AM, a resident was served fish sticks, a broccoli mix, pasta salad, and applesauce, while the resident’s meal ticket for that lunch showed herb baked fish, buttered carrots, and mandarin orange cake. Other residents in the dining room were served the same items, except they received cake instead of applesauce. At 12:06 PM, the survey team was given a sample tray that contained fish sticks, mashed potatoes, a mix of broccoli and vegetables, and cake. The facility’s menu for Day 13 Lunch on Friday, 5/8/26 listed herb baked fish, red beans and rice, spinach, mandarin orange cake, and a beverage. The menu posted in the dining room at 12:02 PM listed herb baked fish, mashed potatoes, mandarin orange cake, and a beverage. The Dietary Manager stated at 1:07 PM that beans were not available because she did not order them, spinach was unavailable because she forgot to order it, carrots were not available so imperial mixed vegetables were served, and fish sticks were typically ordered instead of breaded fish because many residents did not like the breaded fish. The facility’s recipe for herb baked fish called for thawed boneless, skinless fish prepared with margarine, salt, lemon juice, lemon pepper, and parsley, and the facility’s menu changes policy stated posted menus should be modified to reflect menu changes and substitutes for meals should be posted.
Insufficient Nursing Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to ensure there was sufficient nursing staff to meet resident needs and maintain resident safety for 4 of 4 residents reviewed for staffing in a sample of 14. The Facility Assessment listed an average daily census of 56-60 residents and estimated staffing needs of 3 licensed nurses on day shift and 2 on night shift, with 6-7 CNAs on day shift and 5-6 on night shift. However, staff reported lower actual staffing levels, including 5 CNAs on days and 4 on nights, with plans to reduce to 4 on days and 3 on nights. Staff also stated that agency staff were used often, sometimes arrived late, and that the workload was too heavy for the number of CNAs available. Interviews described staffing patterns of 1 nurse and 2 or 3 CNAs for resident groups of 23 and 32 residents, with staff stating this was not ideal and that one more staff member would be helpful. Staff reported difficulty giving CNA breaks, completing work, answering call lights in a reasonable amount of time, and getting showers done. Resident Council minutes documented complaints that a resident did not get a shower and that call lights were turned off and not returned to promptly. During the survey, a resident stated she had only been getting one shower a week for the past month due to a shortage of staff. Deficiencies were also cited during the survey for resident safety, non-pressure wound care, pressure injury identification and assessments, and necessary care and services for multiple residents.
Resident Room Door Obstructed by Bed
Penalty
Summary
The facility failed to ensure a resident room door closed without obstruction to provide privacy for one resident. A CNA stated he provided privacy by shutting the door and pulling the curtain, but later demonstrated that the resident’s bed had to be pushed toward the wall at the head of the bed in order for the door to close properly. When the door was reopened, the bed caught on the door and was moved askew. The CNA said something protruding from the wall at the head of the bed prevented the bed from being placed directly against the wall, leaving the end of the bed obstructing the door. The resident’s care plan documented decreased and impaired mobility, impaired visual function, and dependence on staff for upper body dressing, personal hygiene, bed mobility, and moving between sitting and lying positions. The resident’s diagnoses included type 2 diabetes mellitus with diabetic neuropathy, muscle wasting and atrophy, and lack of coordination.
Inaccurate wound assessments and missed specialty appointments
Penalty
Summary
The facility failed to complete accurate weekly assessments of a resident’s venous stasis wound. R6 had diagnoses including chronic venous hypertension with ulcer of the left lower extremity, chronic pain syndrome, pressure ulcer of the right upper back, and spastic hemiplegia affecting the left nondominant side. The wound summary report showed the same left ankle wound assessment repeated on multiple weekly dates, documenting the wound as full thickness with bright pink or red tissue, light serosanguineous exudate, and measurements of 5.5 cm x 2.0 cm x 0.10 cm. However, the specialty physician wound evaluation completed two days after the last facility assessment described the left ankle wound differently, including a smaller size of 4.8 cm x 1.8 cm x 0.10 cm, heavy serous exudate, 30% slough, and 70% granulation tissue. During observation, the left ankle wound was open with some clear drainage, and staff stated the wound assessments were in a separate wound program that the treatment nurse could not access. The facility also failed to ensure that a resident’s breast biopsy procedure was scheduled and failed to ensure transportation for a dermatology appointment was arranged for another resident. R2’s mammogram showed a right breast lump and recommended clinical correlation for possible skin punch biopsy, and a physician order was entered for referral for an ultrasound-guided biopsy of the right breast. The biopsy was never scheduled while R2 remained at the facility, and there was no documentation explaining why it was not completed. R3 had a physician order for dermatology referral to evaluate and treat painful skin tags, but two dermatology appointments were cancelled. One cancellation was due to the van driver calling off, and the appointment had not been rescheduled at the time of the survey. R3 stated the appointments had been cancelled and that the skin tags caused irritation and discomfort when dressing.
Unsafe Mechanical Lift Transfer
Penalty
Summary
The facility failed to transfer a resident using a mechanical lift in a safe manner. The resident had diagnoses that included diabetes, a lump in the right breast, and morbid obesity. During the lift transfer, the resident was found on the floor with the mechanical lift still attached, and the resident stated that the lift fell and that the side hurt. The resident was sent to the hospital, where X-rays and CT scan results were negative, and the resident was discharged back to the facility the same day in stable condition. The RN who responded said she was called to the room because the resident fell during a mechanical lift transfer and was observed on the floor with the lift still attached. The previous DON stated that the investigation found the base of the lift was not opened wide enough to ensure proper balance, which contributed to the fall. The staff involved were agency CNAs who had not returned to work since the incident.
Failure to Honor Food Preferences and Lactose-Free Diet Orders
Penalty
Summary
The facility failed to ensure that resident meal preferences, intolerances, and allergies were accommodated for 2 of 3 residents reviewed for food preferences and allergies. One resident stated she is lactose intolerant and reported being served pudding and mashed potatoes, and she believed milk was used in the mashed potatoes. The Dietary Manager confirmed the pudding served contained dairy and that lactose intolerant residents could not have it, and also stated the facility used instant mashed potatoes that sometimes required milk, although water-based preparation was usually used. The manager also stated that red beans and rice were not prepared for lunch because the beans were not ordered, and mashed potatoes were substituted instead. Record review showed one resident's lunch meal ticket listed lactose intolerance, a dislike of pudding and potatoes, and an order to be served steamed rice, while another resident's meal ticket listed herb baked fish and red beans and rice despite also noting no fish and lactose intolerance. The first resident's order summary showed a liberalized renal diet with low concentrated sweets and lactose free, and the care plan directed staff to obtain and honor food preferences and provide the ordered diet. The second resident's order summary showed a regular diet with lactose free. The facility's Menu Substitutions Policy stated that food preferences, dislikes, and allergy information are added to the food service program and that kitchen staff will avoid serving allergens and dislikes as noted in the resident profile.
Failure to Perform and Document Daily Surgical Wound Dressing Changes as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care according to physician orders for a resident with a dehisced surgical wound on the right posterior ankle and a history of recurrent wound infections. Surveyors observed the resident in bed with a right ankle dressing dated 2/5/26, despite the resident’s statement that the dressing was supposed to be changed daily but was not being changed. The resident reported the wound had been infected previously and required an injection. The resident’s daughter stated that the facility’s lack of care to the ankle wound led to infection and that the wound improved during the week but worsened on weekends when dressings were not changed. The Assistant DON, who served as the wound care nurse, confirmed the wound was a dehiscence from surgery, ordered for daily dressing changes, and that she personally performed dressing changes during the week, with the last change documented on 2/5/26. Record review showed the treatment administration record ordered daily wound care to the right lower leg, including cleansing, application of medi-honey, and covering with bordered gauze once daily and PRN if saturated, soiled, or dislodged. The TAR reflected that the dressing was changed on 2/6/26, even though the physical dressing remained dated 2/5/26 and the resident stated it had not been changed. The EMR documented three wound cultures over the prior three months, with two cultures positive for gram negative bacilli and one negative culture, and the MAR showed the resident had been treated with Bactrim DS and later ceftriaxone for wound infections. The resident’s care plan identified a dehiscence of the surgical site to the posterior right lower extremity with an intervention of treatment as ordered. The facility’s skin policy required a licensed nurse to observe wound/incision condition daily or with dressing changes and document findings, with physician and responsible party notification for acute changes, but the observed and reported failure to perform and accurately document daily dressing changes demonstrated noncompliance with these requirements.
Failure to Protect Residents from Misappropriation of Funds
Penalty
Summary
The facility failed to protect residents from misappropriation of their funds, as evidenced by discrepancies in resident trust fund accounts for three residents. During a quarterly audit, the Regional Financial Coordinator identified large, unusual cash withdrawals from resident accounts, which were not consistent with the residents' typical spending patterns. Some withdrawals lacked required witness signatures, and in several cases, staff who signed as witnesses did not observe any money being given to the residents. The Business Office Manager, who was responsible for these transactions, claimed to have obtained consent from resident representatives, but no receipts or documentation were found to support these claims. One resident with severe cognitive impairment and multiple diagnoses, including dementia and intellectual disability, had significant sums withdrawn from his account over several months. His room contained minimal personal belongings, and there was no evidence of new purchases. Another resident, who was cognitively intact, had multiple withdrawals from her account, but stated that she did not make purchases herself and her Power of Attorney had not authorized any spending. A third resident, also cognitively intact, had large withdrawals from her account, and the facility was unable to confirm with her guardian whether these were authorized. The investigation revealed that the Business Office Manager had also submitted forged medical documentation to obtain work accommodations and was terminated for violating facility rules. The police were notified, and evidence was collected, but receipts for the withdrawn funds were never produced. The facility's abuse policy affirms residents' rights to be free from misappropriation, but the lack of proper authorization, documentation, and oversight led to the wrongful use of resident funds.
Failure to Notify Physician of Worsening Pressure Injury
Penalty
Summary
The facility failed to notify a resident's physician of a change in the resident's pressure injury status. The resident was admitted with a stage 2 pressure injury to the coccyx/sacral area, which was initially small in size. Over time, wound assessments documented that the wound increased in size and drainage, but the treatment remained unchanged. The wound nurse was responsible for assessing the wound and noted its worsening condition, yet did not update the physician or nurse practitioner about the lack of improvement or the resident not being seen by the wound doctor. The nurse practitioner stated she was present in the facility and monitored the resident's medical condition, except for the wound, as she believed the wound doctor was following the case. However, she was not informed that the wound doctor was not involved. Facility policy required the attending physician to be notified within seven to fourteen days if there was a lack of response to treatment, but this notification did not occur. The resident's spouse also reported that the wound had worsened significantly by the time of hospital discharge.
Failure to Timely Administer Wound Care and Notify Physician of Wound Deterioration
Penalty
Summary
The facility failed to carry out a physician's order for the application of an antibiotic ointment to a resident's left heel ulcer, resulting in a nine-day delay before the treatment was initiated. The order, written by a podiatrist, was not entered into the resident's electronic medical record (EMR) until nine days after it was given, and the antibiotic ointment was not administered during this period. Nursing staff acknowledged that the omission occurred because the nurse who received the order did not enter it into the EMR, causing the treatment to be missed until it was later identified and corrected. Additionally, the facility did not promptly notify a physician when the resident's non-pressure wound showed signs of deterioration. Wound assessments documented an increase in wound size, the development of necrotic tissue, and the onset of drainage over several weeks. Despite these changes, there was no documentation that the physician or nurse practitioner was informed of the wound's worsening condition. The wound care physician was not contacted to assess the wound until more than a month after the deterioration began, and the resident's medical record did not show any refusal of services or documentation of timely notification to the appropriate medical providers. The resident involved had multiple complex medical conditions, including type 2 diabetes with a foot ulcer, chronic kidney disease with end-stage renal disease, and was receiving renal dialysis. The care plan required monitoring the wound and notifying the physician of any changes, such as increased size, drainage, or signs of infection. Facility policies also required prompt entry of physician orders into the EMR and timely notification of physicians regarding changes in wound status, but these procedures were not followed in this case.
Resident Injury Due to Inadequate Supervision
Penalty
Summary
The facility failed to adequately supervise a resident with a metastatic brain neoplasm, resulting in an incident where this resident entered another resident's room and threw a chair at them. This action led to the second resident sustaining a fracture to their right knee, which required hospitalization and ongoing pain management. The incident was documented in the facility's abuse investigation report, and the injured resident's medical records indicate a progression from initial pain complaints to a confirmed fracture diagnosis following multiple imaging tests. The injured resident, who was already on a regimen of Tylenol for pain, required stronger medication, Norco, following the incident. The resident's pain levels were documented as fluctuating between 4/10 and 8/10, necessitating adjustments in pain management. The Director of Nursing and the facility Administrator both acknowledged the incident, confirming that the resident was hospitalized due to the injury sustained from the chair being thrown.
Resident Injured in Facility Van Accident Due to Unsafe Operation
Penalty
Summary
Facility staff failed to operate the facility van safely, resulting in an accident involving a resident. The incident occurred when the Dietary Manager, who was not the regular driver, was operating the van. While entering a parking garage, the van's roof collided with a clearance sign due to the driver's failure to consider the height difference. This collision caused the resident, who was seated in a wheelchair and properly seat-belted, to slide forward and sustain a nondisplaced fracture of the left patella. The resident was subsequently taken to the emergency room for further evaluation and treatment. The facility's Vehicle Safety Program policy emphasizes the importance of safe vehicle operations, but the Dietary Manager had only received a demonstration on how to drive the van, not a comprehensive safety course. The Director of Nursing confirmed that there is a checklist for van driver qualifications, but it appears that the Dietary Manager did not meet all the necessary safety training requirements. The police report corroborated the sequence of events, noting that the van's height clearance was visible to the driver, yet the collision still occurred.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident. The incident involved a resident with severe cognitive impairment, diagnosed with Alzheimer's disease, anxiety disorder, and insomnia, who was subjected to inappropriate sexual behavior by another resident diagnosed with dementia with agitation and other medical conditions. The incident occurred when the second resident was witnessed with his hand under the first resident's sweater. The physical therapist who witnessed the event intervened immediately, separating the residents. The second resident appeared confused, referring to the first resident by a different name, and later expressed regret, indicating he was disoriented and thought he was dreaming. The facility's investigation revealed that the first resident initiated contact by placing the second resident's hand under her sweater, and she did not pull away. Despite the intervention, the facility's video footage of the incident was unavailable for review as it was only saved for a short period. The facility's administrator acknowledged the second resident's confusion and the potential for abuse, as the second resident was aware of his actions, while the first resident was disoriented. The facility's policy prohibits abuse and defines sexual abuse as non-consensual or non-competent to consent sexual activity, which includes unwanted intimate touching.
Failure to Report and Investigate Allegations of Theft
Penalty
Summary
The facility failed to report potential allegations of theft to the Abuse Coordinator and local law enforcement for all 12 residents reviewed for misappropriation of resident property. The facility's Abuse Prevention policy requires employees to report any incident, allegation, or suspicion of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property to the administrator immediately. However, the facility did not adhere to this policy, as several allegations of theft were not reported or investigated properly. The facility's Grievance Logs from September 2024 through January 2025 documented only a few allegations of theft, despite multiple residents reporting missing money and property. For instance, R5 reported missing $88.00, and R12 reported missing $80.00, but the facility could not provide documentation of the investigation outcomes. Additionally, R2, R3, and R8 reported missing money and gift cards, yet there was no documentation of any investigation being initiated. Several staff members, including the Activity Director, Financial Coordinator, and Contracted COTA, acknowledged hearing about thefts but did not ensure these reports reached the administrator or were documented in the Grievance Logs. Interviews with residents revealed a pattern of unreported thefts and a lack of follow-up from the facility. R6 and R7 reported missing money, but their allegations were not documented in the Grievance Logs. R9 and R4 also reported missing money, but only R4's case was investigated, and the police were not notified. R8, R2, R3, and R10 reported missing money, gift cards, and a ring, but these incidents were not properly documented or investigated. The facility's failure to report these allegations to local law enforcement and the Abuse Coordinator, as required by their policy, contributed to the deficiency.
Medication Administration Errors and Delays
Penalty
Summary
The facility failed to ensure medications were administered per the physician's order and facility policy, resulting in significant medication errors for several residents. During a medication administration observation, an LPN was found to have pre-filled medicine cups for a later medication pass, which is against the facility's policy. The LPN was unable to correctly identify all the medications in the pre-filled cup, indicating a potential risk for medication errors. The Director of Nursing confirmed that pre-filling medicine cups is not allowed, highlighting a breach in the medication administration process. Multiple residents reported issues with the timing and accuracy of their medication administration. One resident expressed frustration over missing medications and the impact on their mental health, as they rely on timely administration of psychotropic medications to manage their bipolar disorder. The resident's medication administration record showed instances of late administration, further corroborating their claims. The Director of Nursing acknowledged complaints about late and incorrect medication administration, indicating a systemic issue within the facility. Another resident reported receiving their psych and seizure medications late, sometimes resulting in hospital visits due to the delay. Their medication administration records showed consistent delays in receiving evening medications, which are critical for managing their conditions. A third resident also experienced delays in receiving evening medications, which affected their ability to sleep and manage their anxiety. The facility administrator was aware of the late medication administration but did not document these occurrences as errors, suggesting a lack of accountability in addressing the issue.
Medication Transcription and Administration Error
Penalty
Summary
The facility failed to transcribe and administer medication according to the physician's order for a resident with Parkinson's Disease. The resident's admission orders specified that Carbidopa-Levodopa 25-100mg should be taken two tablets six times daily, and Carbidopa-Levodopa ER 50-200mg should be taken one tablet at bedtime. However, the Medication Administration Record (MAR) incorrectly documented the administration of Carbidopa-Levodopa ER 25-100mg two tablets every four hours. This error was identified by a Nurse Practitioner during a review of the resident's admission orders, who then notified a Registered Nurse to correct the order. The resident received the incorrect medication regimen from the time of admission until the error was discovered.
Failure to Ensure Resident Dignity and Timely Call Light Response
Penalty
Summary
The facility failed to uphold the resident's right to a dignified existence and self-determination by not ensuring staff knocked before entering a resident's room. On one occasion, a housekeeping staff member entered a resident's room without knocking or announcing themselves, which was against the facility's policy. The staff member admitted to being focused on checking the closet and acknowledged the oversight, despite having received training on the importance of knocking before entering a resident's room. The Director of Nursing confirmed that staff are expected to knock and announce themselves prior to entering a resident's room. Additionally, the facility did not respond to call lights in a timely manner for several residents who were dependent on staff for their care. Multiple residents reported waiting between 30 to 45 minutes for assistance after activating their call lights. One resident, who was incontinent and dependent on staff due to a traumatic brain injury, had to wait 45 minutes for assistance with changing an undergarment. The facility's administrator expressed a preference for a quicker response time, indicating that the current wait times were not acceptable.
Failure to Notify Medical Doctor of Resident's Chest Pain
Penalty
Summary
The facility failed to ensure that staff reported a resident's change of condition to a medical doctor. A resident, who was experiencing chest pain, was not immediately reported to a medical doctor as required by the facility's policy. The resident, who has a history of Hypertensive Chronic Kidney Disease, Type II Diabetes Mellitus, Asthma, Anemia, Bipolar Disorder, Hypertension, and is dependent on Renal Dialysis, reported chest pain to a male nurse. The nurse administered Alprazolam and advised the resident to lie down, but did not notify a medical doctor. The resident later reported the chest pain to a night nurse, who attempted to contact the doctor and eventually called 911 when the doctor did not respond. The resident was taken to the hospital for evaluation, where it was determined that the chest pain was likely due to anxiety. The resident expressed that the pain was severe, rating it as 9 out of 10, and described it as radiating down the left arm. The facility's Director of Nursing confirmed that it is expected for staff to notify a medical doctor in cases of chest pain. The incident highlights a failure in communication and adherence to the facility's policy regarding the notification of medical professionals in the event of a significant change in a resident's condition.
Failure to Develop Hand Brace Care Plan
Penalty
Summary
The facility failed to develop a care plan for a resident's hand braces, which were used to prevent contractures. During an observation, the resident was found lying in bed with lamb skin braces on both hands. A hospice note indicated that the braces were for contractures, but the resident's current care plan did not document the use of these braces or the presence of contractures. A registered nurse confirmed that the braces were used to prevent contractures, as the resident kept her hands closed all the time. The Director of Nursing was unaware if the braces were included in the care plan.
Deficiency in ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care for two residents, R73 and R12, as observed during a survey. R73, who is cognitively intact but requires staff assistance for ADLs, was noted to have overgrown and unkempt facial hair and fingernails with a brown/black substance underneath. Despite being scheduled for a shower and personal care on a specific day, R73 did not receive these services as planned, leading to discomfort and dissatisfaction. A Certified Nursing Assistant (CNA) acknowledged that R73 should have received nail care and shaving but had not. Similarly, R12, who has a self-care performance deficit due to conditions such as dementia and legal blindness, was found with dark residue beneath her fingernails on multiple occasions. Although the facility's policy requires daily cleaning of residents' nails, this was not adhered to, as confirmed by a Licensed Practical Nurse (LPN) and two CNAs. The Director of Nursing (DON) also stated that nails should be cleaned whenever they are soiled, indicating a lapse in the facility's adherence to its own care policies.
Failure to Change and Secure Oxygen Equipment
Penalty
Summary
The facility failed to adhere to its policy and procedure for changing and dating oxygen equipment, specifically for a resident using oxygen therapy. The policy, revised in January 2019, mandates that nasal cannulas and oxygen humidifiers be changed weekly and dated, and that residents using portable oxygen tanks should switch to room oxygen concentrators when possible. However, observations revealed that the resident's oxygen cannula and humidifier bottle were undated, and the oxygen tubing connected to the cylinder tank was dated from several weeks prior. The resident confirmed that the night shift nurse was responsible for changing the tubing weekly, but this had not been done. Additionally, the facility did not have a policy for the secure storage of oxygen tanks, leading to a situation where the resident's oxygen cylinder tank was found free-standing and unsecured. The resident reported using the oxygen concentrator in their room and the cylinder tank on their wheelchair when outside the room. The Director of Nursing confirmed that oxygen tubing and humidifier bottles should be changed weekly and that oxygen tanks should not be left unsecured. The failure to follow these procedures resulted in the deficiency noted by the surveyors.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were not left at the bedside for a resident, identified as R43, during a medication administration pass. On June 12, 2024, a registered nurse (RN), V13, brought medications, specifically Lanthanum and Midodrine, into R43's room. R43 requested that the medications be left on the bedside table, and V13 complied, leaving the room without ensuring the medications were ingested. The facility's policy requires that medications be administered according to prescriber's orders and that residents are observed to ensure the medication is ingested, which was not followed in this instance. The facility's Electronic Health Records (EHR) did not document any physician order allowing R43 to self-administer medications. Interviews conducted on June 13 and 14, 2024, revealed that V13 believed it was acceptable to leave the medications with R43 due to her alert and oriented state, although there was no formal order for self-administration. Another RN, V14, confirmed that no residents had orders to self-administer medications, and a Regional Nurse Consultant, V15, stated that a physician's order and assessment are required before leaving medications with residents. This oversight led to a deficiency in medication administration practices at the facility.
Failure to Follow Physician Order for Hospital Transfer
Penalty
Summary
The facility failed to follow a physician's order to send a resident (R2) to the local hospital for evaluation, resulting in a delay of treatment and subsequent admission to the hospital's intensive care unit with multiple comorbidities. The deficiency was identified when the facility did not act on the order given by the dialysis RN, who had observed significant changes in R2's condition, including elevated temperature, decreased oxygen saturation, and mental status changes. Despite the dialysis RN's communication with the facility's nursing staff and the DON, the order was not processed, and R2 was not sent to the hospital as instructed. R2 had a complex medical history, including hypertensive heart and chronic kidney disease with heart failure, end-stage renal disease, type 2 diabetes, and other significant health issues. On the day of the incident, R2 exhibited symptoms such as rales in the upper lobes, a temperature of 100.4, and oxygen saturation at 81% on room air. The dialysis RN contacted R2's nephrologist, who agreed that R2 should be evaluated in the emergency room. However, the facility's DON and nursing staff did not follow through with the order, arguing that R2's condition was due to fluid overload and could be managed with dialysis. The failure to send R2 to the hospital as ordered led to a continued decline in R2's condition. R2 was eventually admitted to the hospital with sepsis, very high troponin levels, and multiple other serious health issues. The facility's progress notes and interviews with staff confirmed that there was a significant delay in addressing R2's deteriorating condition, which contributed to the severity of the situation.
Removal Plan
- All licensed staff were educated, by V2 DON, V9 RNC and V16 QA Nurse Manger, on Notification - Physician Notification on Change of Condition.
- All licensed staff were educated, by V2 DON, on Physician Orders including entering, processing, following and implementation of physician orders.
- All licensed staff were educated, by V2 DON and V9 RNC, on utilizing the back-up medication system and list of medications was posted by back-up medication system.
- V2 DON was educated, by V9 RNC on Change in Condition Assessment, Interventions and Documentation.
- All licensed staff have been re-educated, by V2 DON, V9 RNC, and V16 QA Nurse Manager, on the process to utilize the Dialysis Communication Report including the completion of the facility required information on the communication report.
- All licensed staff have been educated, by V2 DON, V9 RNC, and V16 QA Nurse Manger, on Change in Condition Assessment, Interventions and Documentation.
- V8 Dialysis RN was educated, by V2 DON, that when a physician order is received for a dialysis resident to communicate the order directly to the DON, and if unavailable, report to QA (Quality Assurance) Nurse Manager/ADON (Assistant Director of Nursing).
- The facility Physician-Family Notification-Change in Condition, Emergency Pharmacy and Emergency Kits, and Dialysis monitoring and Observation were reviewed, by V1 Administrator and V9 RNC, with no changes being made to the policies.
- The facility held an immediate QA meeting to address identified concerns, completed chart audits for review of physician orders, dialysis monitoring documentation, wrote physician orders as needed and updated MARS and TARS to reflect Dialysis monitoring. The facility also has Dialysis company scheduled to do directed inservice to nursing staff.
Failure to Follow Dialysis Policy and Procedures
Penalty
Summary
The facility failed to follow its dialysis policy and procedures for the care and monitoring of six residents who required dialysis services. The facility's policy required monitoring for complications, including listening for the bruit and thrill of the fistula, documenting findings, and notifying the physician and dialysis center of any abnormalities. However, the facility did not consistently document or perform these required checks. For example, Resident 1 had incomplete documentation of dialysis monitoring, and there were no physician orders for dialysis treatment, care, or monitoring. Similar issues were found with Residents 2, 3, 4, 5, and 6, where documentation was incomplete or missing for various aspects of dialysis care, including vital signs, access site inspections, and post-treatment assessments. Resident 2 had a tunneled hemodialysis catheter placed but lacked orders for dialysis treatment, care, or monitoring. The progress notes did not document dialysis treatment, care, or monitoring, and the MARs and TARs were incomplete. Resident 3 had physician orders for hemodialysis and access site inspections, but the documentation was incomplete or missing for several days. Resident 4 had orders for in-house dialysis and access site checks, but weights and vital signs were not consistently obtained, and documentation was incomplete for several days. Resident 5 had no physician orders for dialysis treatment, care, or monitoring, and the MARs and TARs showed incomplete documentation. Resident 6 also lacked physician orders for dialysis treatment, care, or monitoring, and the documentation was incomplete for several days. The facility's failure to follow its dialysis policy and procedures resulted in inadequate monitoring and documentation of dialysis care for these residents, potentially putting them at risk for complications.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Marseilles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pavilion Of Ottawa | 5.9 mi | ★★★★★ | 11 | 0 |
| Pleasant View Luther Home | 6.6 mi | ★★★★★ | 3 | 0 |
| La Salle County Nursing Home | 9.2 mi | ★★★★★ | 0 | 0 |
| Serenity Estates At Morris | 14.2 mi | ★★★★★ | 22 | 0 |
| Parker Nursing & Rehab Center | 14.6 mi | ★★★★★ | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.