Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Maries Manor during CMS and state inspections, most recent first.
A resident received another resident's medications after an LPN, who was overwhelmed and assisting multiple residents, failed to verify the medication cup before administration. The resident ingested medications not prescribed to them after picking up the wrong cup from the medication cart while the LPN was distracted. Facility policy requires staff to verify resident identity and administer medications to one resident at a time.
Kitchen Ceiling Damage in Food Prep Area: The kitchen ceiling had multiple cracks, flaking plaster-like material, and sagging, water-stained areas above food prep and storage locations, including the steam table, ware rack, prep counter, bakery, utensil hanger, and coffee pots. The DM said there were small water leaks and the maintenance director was aware of the ceiling issues, while the administrator stated kitchen staff were responsible for reporting building problems and that the facility did not have a policy related to facility ceiling maintenance.
An LPN failed to disinfect a shared glucometer with an approved disinfectant between residents, used the same meter for another resident, and did not perform proper hand hygiene or glove changes during multiple blood sugar checks. The LPN also entered rooms for wound and catheter care for two residents on EBP without wearing a gown. The DON and administrator stated staff were expected to clean hands between tasks and use PPE for residents requiring EBP.
Failure to Implement Antibiotic Stewardship Monitoring: The facility failed to implement an ASP with antibiotic use protocols and a system to monitor and track antibiotic use. The DON said the person responsible for the ASP left, the binder was the only tracking documentation available, and no one was currently fulfilling the role. The administrator said the previous ADON maintained the ASP and was not aware it was not being completed.
Failure to transcribe a treatment order and a Fentanyl patch order accurately led to deficient practice. A resident with a stage 1 pressure injury had Optifoam listed in wound documentation, but the POS and TAR did not contain the treatment order. Another resident with frequent pain and a knee amputation had a Fentanyl patch order for 25 mcg/hr every 72 hours, but the MAR was entered so the patch was given every 96 hours instead of every 72 hours because the repeat cycle was entered incorrectly.
Unsecured Storage and Delayed Destruction of Resident Medications: An unlocked MDS office closet contained multiple containers, bags, and boxes of resident medications, including prescription drugs, nicotine patches, and OTC meds for numerous residents. The MDS Coordinator said the medications had been there for at least a year awaiting destruction, while the DON and Administrator said the medications should not have been stored there and should have been destroyed or returned to the pharmacy sooner.
Facility staff failed to follow professional standards by pre-popping medications and using expired blood sugar test strips. Medications were prepared in advance, contrary to policy, and labeled with only first names. Staff, including a CMT and an LPN, were unaware of the policy details, leading to inconsistent practices. Expired test strips were used for multiple residents, compromising blood sugar reading accuracy. The DON and administrator acknowledged the importance of policy adherence but did not ensure consistent compliance.
The facility staff failed to properly store and label medications, resulting in deficiencies. Observations showed undated multi-dose medication bottles and insulin pens, raising concerns about their effectiveness. Additionally, medications were left unattended on a cart, posing a risk of unauthorized access. Interviews with staff confirmed the responsibility to label medications with open dates and ensure secure storage.
The facility did not employ a qualified Director of Food and Nutrition Services, as required, due to the absence of a full-time qualified dietitian or clinically qualified nutrition professional. The dietary manager lacked the necessary experience and certification, and the facility relied on a part-time consultant dietitian. The administrator was unaware that the qualifications needed to be met upon hire.
The facility was cited for deficiencies in food safety practices, including improper use of facial hair restraints and failure to air dry sanitized dishes. A cook prepared food without a facial hair restraint due to a misunderstanding of policy, and staff were observed stacking wet dishes, which were then used to serve residents. The dietary manager and staff were unaware of the correct procedures, leading to these deficiencies.
The facility failed to ensure call lights were within reach for three residents, despite policy requirements. Observations showed residents with cognitive impairments and total dependency had call lights placed out of reach. Interviews with CNAs, an LPN, the DON, and the administrator confirmed the expectation for call lights to be accessible, yet this was not consistently practiced.
The facility failed to update care plans for two residents, one with severe cognitive impairment and cellulitis requiring a compression boot, and another who was noncompliant with medication intake. Despite physician orders and documented behaviors, the care plans lacked necessary interventions, indicating a gap in communication and documentation.
Medication Administration Error Resulting in Resident Receiving Another's Medications
Penalty
Summary
Facility staff failed to ensure that a resident remained free from accidents when one resident received another resident's medications. According to the facility's policies, staff are required to safeguard residents, provide emergency care as needed, and administer medications in accordance with physician orders, verifying the resident's identity prior to administration. On the day of the incident, an LPN prepared medications for two different residents. One resident initially refused their medications and requested to take them later, while the other also refused their medications. The LPN placed both sets of medications in the medication cart and became occupied assisting other residents. When the first resident later requested their medications, the LPN inadvertently placed the wrong medication cup on the cart without verifying the label. While the LPN was distracted retrieving a spoon, the resident picked up the cup containing the other resident's medications, mixed them with pudding, and ingested them. Review of records confirmed that the medications ingested were not prescribed for the resident who consumed them. Interviews with facility staff, including the administrator and DON, revealed that staff are instructed to verify resident identity and administer medications to one resident at a time. Both acknowledged that the LPN was overwhelmed and assisting multiple residents at the time of the error, which contributed to the failure to follow established medication administration protocols.
Kitchen Ceiling Damage in Food Preparation Area
Penalty
Summary
The facility failed to maintain the kitchen ceiling in good repair to prevent contamination of food items. During observation, the kitchen ceiling was covered with a white textured, plaster-like material and had multiple areas of damage, including a 33-inch crack above the end of the steam table with the ceiling sagging on one side, a 22-inch crack with white flaking material above the ware storage rack near the service window, a 16-inch crack between the prep counter and bakery, a 3-inch area of white flaking material above the steam table, and a 4-inch area of white flaking material above the ceiling-mounted utensil hanger. Additional observation showed two areas of white flaking ceiling material and a sagging, water-stained area near the coffee pots. The Dietary Manager stated awareness of the ceiling cracks and reported small water leaks in the ceiling, with the maintenance director also aware of the issues. The maintenance director stated there had been condensation over the past few weeks and repairs were delayed until the areas dried. The administrator stated kitchen staff were responsible for reporting building issues, that the kitchen ceiling should not have cracks or flaking areas because materials could fall into food, and that the facility did not have a policy related to facility ceiling maintenance.
Failure to Follow Infection Control Practices During Glucose Monitoring and EBP Care
Penalty
Summary
Facility staff failed to appropriately sanitize a multi-use glucometer between blood glucose checks for two residents. On 08/13/25, an LPN obtained one resident’s blood sugar with the glucometer, exited the room, and wiped the meter with an alcohol pad rather than an approved EPA-registered disinfectant. The same glucometer was then used for another resident. During interview, the LPN stated the approved Sani-Cloth wipes were not available and said he/she did not ask for any. Facility staff also failed to perform appropriate hand hygiene and glove changes during blood glucose monitoring for three residents. On 08/11/25, an LPN entered three different residents’ rooms for blood sugar checks without washing or sanitizing hands before donning gloves. After each check, the LPN removed the test strip by the blood-saturated tip and then touched the computer mouse, computer, and other items on the medication cart with the same soiled gloves. The facility’s glove policy directed staff to change gloves between residents and between contacts with different body sites of the same resident. The DON stated staff should wash or sanitize hands before and between blood sugar checks and remove gloves after checks. Staff also failed to use PPE for two residents on enhanced barrier precautions during wound care and/or catheter care. One resident had a wound and a catheter, and another resident had wounds with a care plan directing EBP for wound care. Observations showed an LPN entered each resident’s room to perform wound and catheter care without putting on a gown. The facility’s EBP guidance identified residents with wounds or indwelling devices as requiring EBP, and the DON and administrator stated staff were expected to wear gowns and gloves for these residents.
Failure to Implement Antibiotic Stewardship Monitoring
Penalty
Summary
The facility failed to implement an Antibiotic Stewardship Program with antibiotic use protocols and a system to monitor and track antibiotic use within the facility. Review of the facility’s policy titled, "Antibiotic Stewardship Program," dated 4/10/25, showed that the DON was responsible for auditing clinical assessment documentation at the time of antibiotic prescription, including Stop and Watch, SBAR, physician communication, and follow-up diagnostic testing. The policy also required auditing of antibiotic prescribing documentation for dose, route, start date, end date, days of therapy, and indication, and stated that the Antibiotic Stewardship Program team would monitor antibiotic starts by indication. Review of the facility’s antibiotic stewardship program showed facility staff did not track antibiotic trends. During interview, the DON said the person responsible for the Antibiotic Stewardship Program left two weeks earlier and that the binder provided was the only documentation available for tracking and trending antibiotics and infections. The DON stated that the MDS Coordinator and he/she were both certified as infection preventionists but neither had time to fill the position, so no one was currently fulfilling the role. The administrator later stated the previous ADON was responsible for maintaining the ASP and said he/she was not aware that the Antibiotic Stewardship Program was not being completed.
Failure to Transcribe Treatment and Medication Orders Accurately
Penalty
Summary
Facility staff failed to maintain professional standards of practice when a treatment order for a resident with a stage 1 unhealed pressure injury was not transcribed into the resident’s chart. Resident #7’s MDS showed the resident was cognitively intact, at risk for pressure ulcers/injuries, and had a stage 1 unhealed pressure injury. The resident’s wound documentation showed an admission finding of a stage 1 decubitus ulcer on the right inner buttock with Optifoam listed as the treatment, but the POS did not contain an order for Optifoam and the TAR did not contain the treatment. The DON stated the admitting nurse was expected to contact the doctor to verify orders and that the DON was responsible to check that orders were correct, but the order was not in the chart and was missed. Facility staff also failed to accurately transcribe a Fentanyl patch order for a resident with frequent pain and a knee amputation due to a wound infection. Resident #75’s MDS showed the resident was cognitively intact and experienced frequent pain, and the plan of care included monitoring pain and giving medications as ordered. The POS showed an order for a Fentanyl patch 25 mcg/hour every 72 hours, but the MAR reflected administration every 96 hours instead of every 72 hours because the MDS Coordinator entered the repeat cycle incorrectly into the electronic MAR system. The MDS Coordinator stated the error was identified later and that the prescribing physician verified the correct order was every 72 hours. The DON and administrator stated the nurse receiving the telephone order was responsible for entering it correctly and that staff should verify orders were entered accurately.
Unsecured Storage and Delayed Destruction of Resident Medications
Penalty
Summary
Drugs and biologicals were not stored in accordance with facility policy and accepted storage principles when multiple residents’ discontinued or unused medications were found unsecured in the MDS Coordinator’s office closet. The office was observed unlocked, and the closet contained several containers, boxes, trash bags, and grocery bags holding resident medications. The facility’s policy required medications to be kept in a locked cabinet, locked medicine room, or locked medication cart, and medications not returned to the pharmacy were to be destroyed at least weekly. The closet contained medications for 27 residents, including antidepressants, antipsychotics, diabetes medications, cardiovascular medications, anti-inflammatory medications, and other drugs. Examples included Mirtazapine, Quetiapine, Metformin, Glipizide, Atorvastatin, Citalopram, Fluoxetine, Celecoxib, Trazodone, Famotidine, Warfarin, Lurasidone, Risperidone, Bupropion, Amantadine, Valacyclovir, Benztropine, Rexulti, nicotine patches, and multiple over-the-counter medications. Many of the pharmacy fill dates were months to years old, and one container was observed half full of loose tablets and capsules wrapped in a grocery bag. The MDS Coordinator stated the medications had been in the closet for at least a year and were waiting to be destroyed, and said the medications should have been destroyed. The DON said he/she was not aware the medications were stored in the MDS office and stated they should not have been there. The DON said discontinued or expired medications were expected to be destroyed or returned to the pharmacy within a couple of days, and the Administrator said staff should have destroyed or returned medications to the pharmacy monthly.
Medication and Blood Sugar Testing Deficiencies
Penalty
Summary
The facility staff failed to adhere to professional standards of medication administration by preparing medication cups in advance of the scheduled medication pass. Observations revealed that medication cups were pre-popped and labeled with only first names, containing various pills, including narcotics. Certified Medication Technician (CMT) C admitted to pre-popping medications due to a lack of medication cards, despite the facility's policy prohibiting such practice. Licensed Practical Nurse (LPN) D also pre-popped medications for multiple medication passes, unaware of the facility's policy against it. The Director of Nursing (DON) and the administrator were not fully aware of the policy details, leading to inconsistent practices. Additionally, the facility staff used expired blood sugar test strips for four residents, potentially compromising the accuracy of blood sugar readings. LPN E used expired test strips for multiple residents and was unaware of the need to check expiration dates or label strips with an open date. The DON and the administrator acknowledged the importance of checking expiration dates but did not ensure that staff adhered to this practice consistently. The facility's failure to follow its own policies regarding medication administration and blood sugar testing resulted in deficiencies in the quality of care provided to residents. The lack of awareness and adherence to policies by staff, including the DON and the administrator, contributed to these deficiencies, highlighting a need for improved oversight and training to ensure compliance with professional standards.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility staff failed to store and label medications properly, leading to deficiencies in medication management. Observations revealed that multiple opened multi-dose medication bottles, including magnesium oxide, vitamin D, vitamin B-1, a multi-vitamin, saline nasal spray, latanoprost ophthalmic solution, and fluticasone nasal spray, were undated. Interviews with a Certified Medication Tech (CMT), a Licensed Practical Nurse (LPN), the Director of Nursing (DON), and the administrator confirmed that it is the responsibility of the staff opening the bottles to label them with the open date. The lack of open dates on these medications raised concerns about their effectiveness and safety. Additionally, the facility's insulin management was found to be deficient. The insulin cart contained several opened insulin pens and vials, such as Levemir Flex touch pens, Lantus SoloStar pens, Humalog Kwik pen, and Humulin R vial, which were undated. The LPN and DON acknowledged the importance of labeling insulin with open dates to track expiration accurately. The failure to date these insulin products could result in administering ineffective insulin to residents. Furthermore, the report highlighted an incident where medications were left unattended on top of a medication cart. The unattended medications included Senna-Plus, Tylenol, Fluticasone Propionate nasal spray, and Betamethasone Valerate cream. Interviews with the CMT, LPN, DON, and the administrator emphasized the expectation that medications should be stored securely in a locked cart or medication room to prevent unauthorized access. The unattended medications posed a risk of being accessed by residents or visitors, which was not in compliance with the facility's medication storage policy.
Failure to Employ Qualified Director of Food and Nutrition Services
Penalty
Summary
The facility failed to designate a qualified Director of Food and Nutrition Services, as required, due to the absence of a full-time qualified dietitian or other clinically qualified nutrition professional. The facility's Dining Services Supervision policy, dated May 2015, mandates that a full-time qualified Dining Services Manager should oversee the department, with consultation from a qualified individual if the manager is not qualified. However, the policy lacked specific education and experience requirements for the dining services manager. The current dietary manager (DM) was hired in March 2024, but their personnel records did not show the necessary two years of prior experience in a nursing facility or the required certification or education for the position. Interviews revealed that the DM had previously worked at the facility as a dietary manager from 2012 to 2014 and was a certified nursing assistant before that, without any formal education or certification in food service management. The administrator confirmed the DM's lack of qualifications and stated that the facility's policy was to enroll the DM in a certification course after a 90-day probationary period, not realizing the qualifications needed to be met upon hire. The facility relied on a part-time consultant registered dietitian who visited once a month, with no full-time certified or clinically qualified nutrition staff employed.
Deficiencies in Food Safety Practices
Penalty
Summary
The facility was found to have deficiencies in food safety practices, specifically related to the use of facial hair restraints and the proper drying of sanitized dishes. Observations revealed that a cook with facial hair was preparing food without a facial hair restraint, contrary to the facility's posted guidelines and the administrator's expectations. The dietary manager was unaware of the correct policy, believing that facial hair restraints were only necessary for facial hair longer than a quarter inch, based on outdated signage. This misunderstanding led to the cook not wearing the required facial hair restraint while preparing meals for residents. Additionally, the facility failed to ensure that sanitized dishes were allowed to air dry before being stored. Observations showed that metal pans, plastic food storage containers, and food service trays were stacked while still wet, and these wet trays were used to serve food to residents. Interviews with staff indicated a lack of awareness about the requirement for dishes to be dry before storage, despite the dietary manager's belief that staff had been trained on this procedure. The administrator confirmed that staff should allow dishes to air dry and that the dietary manager was responsible for monitoring dish storage practices.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility staff failed to ensure that call lights were within reach for three residents, leading to a deficiency in care. The facility's policy mandates that call lights should be conveniently positioned for residents' use and checked at regular intervals. However, observations revealed that the call lights for three residents were not within reach on multiple occasions. Resident #18, with moderate cognitive impairment and dependent on assistance for transfers and personal hygiene, was observed in a broda chair with the call light placed on the bed, out of reach. Similarly, Resident #44, who was totally dependent for activities of daily living and transfers, was repeatedly observed with the call light on the bed behind them, not within reach. Resident #51, with severe cognitive impairment and total dependency, was also found with the call light draped over a bedside table or on the arm of a recliner, both out of reach. Interviews with facility staff, including CNAs, an LPN, the Director of Nursing, and the administrator, confirmed that call lights should be within reach of residents at all times. Despite this understanding, the observations indicated a failure to adhere to this policy, as the call lights were not consistently placed within reach after care was provided. The deficiency was identified through a combination of observations, interviews, and record reviews, highlighting a lapse in ensuring residents' ability to call for assistance when needed.
Failure to Update Care Plans for Residents with Specific Needs
Penalty
Summary
The facility staff failed to review and revise the care plans for two residents, leading to deficiencies in their care. Resident #3, who has severe cognitive impairment and diagnoses including peripheral vascular disease, diabetes, and dementia, was observed multiple times with a compression boot on the lower left extremity. However, the resident's care plan did not include any direction or interventions for the use of the compressive boot, despite a physician's order to check legs daily and apply the boot for cellulitis. This oversight indicates a lack of adherence to the facility's policy that requires care plans to be updated with any changes in the resident's condition or treatment. Similarly, Resident #47, who is cognitively intact and has a history of non-traumatic brain injury, was found to be noncompliant with medication intake, attempting to conceal pills. Despite this behavior being documented in nurses' notes, the resident's care plan lacked specific interventions to address the noncompliance. Interviews with facility staff, including LPNs and the MDS Coordinator, revealed that there was an expectation for such behaviors to be care planned, but the necessary updates were not made. The Director of Nursing and the Administrator confirmed that medication issues should be included in the care plan, highlighting a gap in communication and documentation within the facility's care planning process.
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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 Vienna
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dixon Nursing & Rehab | 15 mi | — | 0 | 0 |
| Stonebridge Westphalia | 17.5 mi | ★★★★★ | 0 | 0 |
| St Elizabeth Care Center | 17.6 mi | ★★★★★ | 0 | 0 |
| Silverstone Place | 17.7 mi | ★★★★★ | 1 | 0 |
| Cedar Pointe | 18.4 mi | ★★★★★ | 0 | 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.