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 October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Living Center, The during CMS and state inspections, most recent first.
The facility failed to notify the resident representative and/or physician of changes in condition or treatment for two residents. One resident with severe cognitive impairment developed a rash and was treated with permethrin cream, but family was not informed until they questioned staff after seeing the rash. Another resident with CVA, hemiparesis, and TBI displayed verbally aggressive behavior toward another resident, but staff did not document notifying the family or physician as directed in the care plan.
A resident with TBI, stroke-related deficits, depression, and anxiety repeatedly displayed verbal aggression toward a former roommate, including threats, profanity, and blocking the other resident’s path in common areas. Although staff separated the residents at times and the resident was later sent to the ED for an aggressive reaction, the care plan did not identify the ongoing aggression toward the specific resident or include targeted interventions, and staff interviews showed inconsistent awareness and poor communication about the conflict.
A resident with a central venous catheter, renal insufficiency, moderate cognitive impairment, and recent dialysis had a dressing change performed without proper infection control practices. Staff did not have EBP signage or PPE available at the room entrance, placed dressing supplies on an unclean bedside table, failed to maintain a clean field, and donned sterile gloves without hand hygiene before using the same gloves to cleanse and dress the catheter site.
A deficiency was cited when an area of the facility was found to contain accident hazards and lacked adequate supervision to prevent accidents. The environment did not meet required safety standards, resulting in insufficient oversight.
The facility failed to maintain cleanliness and proper storage practices for ice machines and food items, leading to several deficiencies. Observations revealed debris buildup in ice machines, improper storage of ice scoops, and inadequate air gap in the refreshment area ice machine. Additionally, two refrigerators consistently recorded temperatures above the acceptable range, storing perishable items without corrective action. Interviews indicated a lack of awareness and communication among staff regarding these issues.
The facility failed to complete MDS assessments within the required timeframe for several residents. The MDS coordinator fell behind due to covering additional duties, resulting in assessments being completed late. The DON and administrator were unaware of the required timeframes, and the facility lacked a specific policy for MDS completion.
The facility failed to document appropriate diagnoses or behaviors to justify the continued use of antipsychotic medications for several residents. Despite recommendations for dose reductions, physicians disagreed without providing rationale. Additionally, the facility did not complete 14-day reviews for PRN lorazepam use, lacking documentation for extended use.
A resident's phone was taken by a CNA, who attempted to make unauthorized purchases using the resident's online shopping account. The CNA changed the phone account password and added their address to the shopping account. The resident's family discovered the issue, leading to police involvement and the cancellation of the transaction.
Failure to Notify Resident Representatives and Physician of Changes in Condition
Penalty
Summary
The facility failed to promptly notify the resident, the resident’s physician, and/or the resident’s representative of changes in condition or treatment for two residents. The facility policy required notification within 24 hours of a significant change in a resident’s medical, mental, or psychosocial status and documentation of those notifications in the medical record. For one resident with severe cognitive impairment who required extensive assistance with personal care, staff documented redness, scratches, and rashes on the lower extremities and back on a shower sheet. The resident’s physician later ordered permethrin 5% topical cream for the rash, but the record showed no documentation that the resident’s family was notified of the rash, the suspected scabies, or the new treatment when the order was received. The resident’s second next of kin reported learning about the treatment only after visiting the resident and questioning staff about the rash, and said the resident had been scratching to the point of bleeding. For another resident with diagnoses including CVA, hemiparesis, and traumatic brain injury, and with a care plan directing staff to observe mood and notify the nurse/primary care physician of changes, the resident displayed verbally aggressive behavior toward another resident in the dayroom. Staff redirected the resident to his/her room and separated the residents, but the record showed no documentation that the resident’s family or physician was notified of the behavior. The resident’s family member later stated the facility did not notify him/her of the incident and wanted notification whenever the resident exhibited verbal behaviors.
Failure to Address Ongoing Verbal Aggression Between Two Residents
Penalty
Summary
The facility failed to ensure that a resident with a traumatic brain injury, stroke-related deficits, depression, anxiety, and intermittent irritability received appropriate treatment and services to support mental and psychosocial well-being. The resident had a history of becoming verbally aggressive toward a former roommate, including threatening to beat the roommate and using profanity toward the roommate in common areas. The resident’s care plan identified general irritability, depression, anxiety, and the need to observe mood and notify the physician of changes, but it did not identify the resident’s repeated verbally aggressive behaviors toward the former roommate or include specific interventions to address those behaviors. After an initial incident in which the resident threatened the former roommate in the dining room, staff separated the residents for the rest of the day, but the care plan was not updated to reflect the behavior or targeted interventions. A later behavior management evaluation documented another episode in which the resident expressed an intent to harm the other resident, and staff notified the RN and the resident’s family. The resident was later sent to the emergency department after another confrontation involving the former roommate, where the resident had blocked the other resident’s path, used profanity, and was diagnosed with an aggressive reaction and given hydroxyzine. The resident continued to display verbally aggressive behavior toward the former roommate after these events, including cursing at the resident in the dayroom and refusing to move away when directed by staff. The care plan remained general and continued to describe irritability, staring triggers, limited abilities, poor safety awareness, and impulsivity, but still did not identify the ongoing aggression toward the former roommate or specific interventions for that behavior. Staff interviews reflected inconsistent awareness of the ongoing conflict, with some staff stating there were no further issues and others stating the problem was ongoing and communication between shifts was poor. The physician and family member both described the residents as not getting along, and the physician stated staff should monitor them like other residents, while the facility administrator stated she would not expect the care plan to contain specific interventions related to the other resident.
Infection Control Lapses During Central Venous Catheter Dressing Change
Penalty
Summary
The facility failed to ensure acceptable infection control practices during a central venous catheter dressing change for a resident with renal insufficiency, moderate cognitive impairment, dependence on staff for personal care, and recent dialysis use. The resident’s care plan directed dialysis care to the port as ordered, and the physician order required the hemodialysis catheter dressing to be completed on Tuesday, Thursday, and Saturday with the resident and nurse wearing masks and the site cleansed with alcohol wipes before being covered with a 4x4 dressing and Tegaderm. During observation, the resident’s room did not have Enhanced Barrier Precautions signage posted and no accessible PPE was available at the entrance. RN A entered the room, sanitized hands, donned gloves and a mask, and placed supplies directly on the resident’s bedside table without cleaning the surface or using a clean barrier. RN A removed the old dressing, changed gloves, and then handled sterile dressing supplies after placing them partly on a paper towel while the unopened alcohol pad remained on the unclean bedside table. RN A opened the sterile gloves, drain sponge, and Tegaderm, then put on the sterile gloves without washing or sanitizing hands and used the same gloves to cleanse the catheter site and apply the dressing. RN A stated the dialysis clinic had not specified a sterile dressing and acknowledged the table should have been cleaned before the dressing change. The dialysis nurse manager stated the resident had a surgically placed central venous catheter in the right upper chest and expected infection control precautions, including a clean field and frequent glove changes, during the dressing change.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to prevent potential incidents. No additional details regarding the specific hazards, the individuals involved, or their medical conditions at the time of the deficiency are provided in the report.
Deficiencies in Ice Machine Cleanliness and Refrigerator Temperature Control
Penalty
Summary
The facility failed to maintain cleanliness and proper storage practices for ice machines and food items, leading to several deficiencies. Observations revealed that two ice machines had a buildup of debris, and the ice scoop was improperly stored, making direct contact with soiled surfaces. Additionally, the refreshment area ice machine lacked an adequate air gap, and the drain was directly connected to the sink drain, which is against the facility's policy. These issues were not addressed despite the facility's policy requiring regular cleaning and maintenance of ice machines. The facility also failed to maintain appropriate temperatures in two refrigerators used for storing food items. The temperature logs showed that the refrigerators consistently recorded temperatures above the acceptable range, with one refrigerator reaching up to 60 degrees Fahrenheit. Despite these readings, the refrigerators continued to store perishable items such as eggs, salads, and beverages. The Dietary Director and the Director of Facilities Maintenance were unaware of the high temperatures, and no immediate action was taken to address the malfunctioning units. Interviews with facility staff revealed a lack of awareness and communication regarding the maintenance issues. The Dietary Supervisor, who had been in the position for two weeks, was not informed about the high temperatures in the kitchen refrigerator or the presence of an ice machine in the central refreshment area. The Director of Facilities Maintenance was also unaware of the debris buildup in the ice machines and the temperature issues with the refrigerators. This lack of awareness and communication contributed to the ongoing deficiencies in maintaining proper food safety standards.
Failure to Complete MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments were completed within the federally mandated time frame for several residents. Specifically, the MDS assessments for five residents were not completed within the required 14 days after the Assessment Reference Date (ARD). The facility's census was 69, and the deficiency was identified during interviews and record reviews. The MDS coordinator, who was responsible for completing the assessments, admitted to falling behind due to covering for another coordinator on medical leave and additional duties on the floor during staff turnover. The coordinator acknowledged that the MDS assessments should be completed within 14 days of the ARD, as per the Resident Assessment Instrument (RAI) manual. However, the assessments for the sampled residents were completed late, ranging from 1 to 37 days past the required timeframe. Interviews with the Director of Nursing (DON) and the administrator revealed a lack of awareness and understanding of the MDS completion process and the required timeframes. The DON was not familiar with the RAI manual and only signed off on the completed assessments, while the administrator recently became aware of the delays in MDS completion. The facility did not have a specific policy related to MDS completion, relying solely on the RAI manual for guidance.
Inadequate Documentation for Psychotropic Medication Use
Penalty
Summary
The facility failed to adequately document appropriate diagnoses or resident behaviors to justify the continued use of antipsychotic medications for several residents. For Resident #56, the facility administered quetiapine for insomnia without a documented diagnosis supporting its use. Despite recommendations from the consulting pharmacist for a gradual dose reduction, the attending physician disagreed without providing a clear rationale. The resident's records showed no documentation of behaviors related to dementia without behavioral disturbance, and observations indicated the resident was generally cooperative and calm. Resident #12 was prescribed quetiapine for dementia with anxiety, but the diagnosis of anxiety was not considered appropriate for the medication. The physician disagreed with the pharmacist's recommendation for a dose reduction without providing a rationale. The resident's care plan indicated the use of antipsychotic medication for anxiety and sleep, but there was no documented psychiatric diagnosis to support the continued use of the medication at the current dose. For Resident #34, the facility continued the use of risperidone and fluoxetine without documented justification for their continued use at the current doses. The physician disagreed with the pharmacist's recommendation for a dose reduction but did not provide a rationale. The resident's care plan and observations showed no documented behaviors that would justify the use of these medications. Additionally, the facility failed to complete a 14-day review for the PRN use of lorazepam for several residents, including Residents #42, #57, and #63, without documented rationale for extending the use beyond the 14-day stop date.
Misappropriation of Resident's Property by CNA
Penalty
Summary
The facility failed to protect a resident from the misappropriation of property when a Certified Nurse Aide (CNA) took the resident's cellular phone and attempted to make unauthorized charges to the resident's online shopping account. The incident involved a resident who was his/her own responsible party and had been readmitted to the facility. The CNA changed the password on the resident's cellular phone account and added their home address to the resident's online shopping account, attempting to purchase items worth approximately $200. The resident's family member discovered the unauthorized changes and purchases, which led to the cancellation of the transaction before it was completed. The incident was reported to the facility administrator after the resident's family member noticed the changes and missing phone. The family member had been unable to locate the phone using the 'Find my Phone' app and reported the issue to the facility. The police were involved, and a report was filed, indicating probable cause that the CNA committed a criminal offense. The resident was unaware of who took the phone and did not notice it was missing until the family member inquired about it. The CNA worked the night shift on the resident's hall when the phone went missing.
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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 Marshall
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Legendary Health Care Center | 1.9 mi | ★★★★★ | 2 | 0 |
| Apple Ridge Care Center | 18.2 mi | ★★★★★ | 5 | 0 |
| Lutheran Nursing Home | 20.5 mi | ★★★★★ | 4 | 0 |
| Katy Manor | 22.2 mi | ★★★★★ | 0 | 0 |
| Glasgow Gardens | 22.4 mi | ★★★★★ | 0 | 0 |
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