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 Marshfield Care Center For Rehab And Healthcare during CMS and state inspections, most recent first.
A resident with depression and socially inappropriate behaviors was placed on one-to-one supervision and 15-minute checks after an incident with another resident, but staff also restricted the resident from eating in the dining room, smoking with other residents, visiting friends, and participating in activities. Staff and observations confirmed the resident was kept in the day room, told to stay away from residents of the opposite sex, and made to smoke alone, while one staff member stated that preventing a resident from talking with others in a common area could be considered isolation.
The facility did not provide timely showers in accordance with resident preferences and care plans, resulting in several residents experiencing long gaps between showers and expressing dissatisfaction with their hygiene. Staff interviews revealed that showers were often missed due to staffing shortages and lack of a dedicated shower aide, and documentation of bathing and skin assessments was incomplete or missing.
Surveyors found the medication room cluttered with a large quantity of unused medications, including various prescription drugs awaiting destruction, due to the facility's failure to maintain a timely process for medication disposal. Multiple staff, including a CMT, LPN, ADON, and DON, acknowledged the ongoing disorganization and backlog, with the DON stating that the process and paperwork for destruction had not been completed for months.
Controlled substances were diverted through improper ordering and receiving. An ADON created and signed for repeated oxycodone orders for multiple residents, often using a physician name that was no longer current, then discontinued many of the orders shortly afterward. Pharmacy records showed repeated 90-tablet fills signed for by the ADON, while staff and the pharmacist stated the narcotics were picked up or controlled by the ADON and never made it to the med cart or nursing staff.
A resident's code status was not clearly documented or accessible in required locations, leading to a delay when staff could not quickly determine the appropriate emergency response during a medical event. Staff interviews revealed that code status information was inconsistent and not updated due to a vacancy in the Social Services Director position, resulting in confusion and delayed initiation of CPR.
A resident with multiple medical conditions suffered a fall resulting in a fracture, but staff failed to notify the family and physician promptly, did not complete or document a full assessment or neurological checks, and did not initiate required fall monitoring. The facility also lacked policies and procedures for fall documentation and notification.
The facility failed to ensure that ordered medications were available and administered as prescribed, resulting in three residents missing multiple doses of essential medications. Staff did not consistently notify physicians when medications were unavailable, and there was confusion among staff regarding the use of the emergency medication kit and the process for obtaining medications for new admissions.
A resident with multiple risk factors for skin breakdown experienced deterioration and infection of pressure ulcers due to staff failing to provide wound care as ordered, incomplete and untimely wound assessments, and lack of care plan updates. Wound treatments were frequently undocumented or missed, and communication lapses among staff led to delayed recognition and management of new and worsening wounds, ultimately resulting in hospitalization for wound infection and abscess.
Staff failed to perform proper hand hygiene and did not follow Enhanced Barrier Precautions during wound care for three residents, including those with MRSA and surgical wounds. Supplies were reused after being dropped on the floor, shared between residents without disinfection, and EBP signage and PPE carts were not consistently available. Staff interviews revealed a lack of training and awareness regarding EBP, and facility policies on infection control were not followed in practice.
Surveyors found that food was not consistently protected from contamination due to unclean kitchen and serving areas, including debris and dried substances on the steam table, plate warmer, and toaster, as well as expired condiments in the serve-out refrigerator. Staff interviews revealed cleaning responsibilities were shared but not always completed due to limited staffing, and there was no clear policy for kitchen cleaning.
A staff member witnessed another staff verbally abusing a resident with cognitive impairment and reported it to the charge nurse, but the incident was not documented or reported to administration or the State Survey Agency within the required two-hour timeframe. The online report was submitted the next morning, and there was no evidence of timely investigation or proper notifications as required by facility policy.
A facility failed to promptly and thoroughly investigate an allegation of verbal abuse after a nurse aide reported witnessing another aide use profane language toward a resident with cognitive impairment and physical debility. The investigation was delayed, lacked comprehensive staff interviews, and did not include timely documentation or proper notifications, contrary to facility policy.
The facility failed to maintain food safety by improperly stacking wet dishware, not separating dented cans, and not ensuring staff wore appropriate hair restraints. Observations showed wet cups stacked together, dented cans stored with others, and a dietary aide with hair exposed while handling food, contrary to facility policies and FDA Food Codes.
The facility failed to provide written notification to residents and/or their representatives for hospital transfers, as required by policy. Three residents were transferred without documented notification, despite multiple instances of hospital transfers due to health issues. Interviews with staff revealed a lack of awareness and practice regarding the provision of transfer forms.
The facility failed to provide written notification of its bed-hold policy to residents or their representatives upon hospital transfer. Three residents were transferred without receiving the required documentation, despite the facility's policy. Interviews revealed staff were unaware of the requirement, indicating a systemic issue in policy adherence.
The facility failed to maintain a sanitary environment in the kitchen and dining areas, with dead bugs found in light fixtures. Observations showed bugs in multiple lights, and interviews revealed a lack of communication and awareness among staff regarding maintenance responsibilities. The facility lacked a policy for light fixture maintenance, contributing to the oversight.
A resident with bradycardia and Parkinson's disease was administered diltiazem despite physician orders to hold the medication if systolic blood pressure was below 110 mmHg. The medication was given on multiple occasions when the resident's blood pressure was below this threshold, as documented by a CMT. Interviews with staff, including the LPN, DON, and Administrator, confirmed the failure to adhere to the prescribed parameters, highlighting a deficiency in medication monitoring.
A resident with diabetes received insulin without the pen being primed, as required by the manufacturer's instructions. An LPN administered the insulin without priming, believing it was unnecessary, despite the resident's high blood sugar level. Interviews revealed inconsistent practices among staff, with the DON confirming that priming is part of the training provided. Facility policies did not address priming insulin pens.
A facility failed to maintain an effective pest control program, resulting in a gnat infestation in a room shared by two residents. One resident, with no cognitive impairment, reported that the other, with severe cognitive impairment, left food and cups in the room, attracting gnats. Staff were aware of the issue but did not effectively address it, and the Administrator was unaware of the problem until it was pointed out. Despite some efforts, the facility's actions were insufficient to prevent the ongoing presence of gnats.
Resident Restricted From Normal Social Interaction After Behavioral Incident
Penalty
Summary
The facility failed to ensure a resident with a diagnosis of depression and documented socially inappropriate/disruptive behaviors was treated with dignity and respect when staff restricted the resident from normal interaction with other residents. After an incident in which the resident acted inappropriately toward another resident, staff placed the resident on one-to-one supervision and 15-minute checks, and the care plan directed staff to remove the resident from unsafe situations, divert behavior, and move the resident to a calm environment when inappropriate. However, staff also limited the resident’s access to common resident activities and interactions beyond the specific incident. The resident reported that staff told him/her he/she was not allowed to smoke with other residents, had to smoke alone after the other smokers finished, had to sit in the day room during the day to be watched by staff, was not allowed to participate in activities, and was not allowed to visit with friends at the facility. Another resident stated that the two residents used to visit every day, but staff no longer allowed them to visit because the resident was on restrictions, even though the other resident said there had been no inappropriate behavior toward him/her. Staff interviews confirmed that the resident was not allowed to smoke with other residents, was to eat meals in the day room by himself/herself, and was not to be in the vicinity of residents of the opposite sex. Observations showed the resident eating meals in the day room rather than in the dining room with other residents, and staff repeatedly directed the resident to keep away from other residents. Multiple staff members stated the resident had to smoke alone, could not visit with other residents, and was restricted from being around residents of the opposite sex. One staff member stated that keeping a resident from talking to other residents and not letting the resident visit with alert and oriented residents in a common area would go against resident rights and could be considered isolation.
Failure to Provide Timely Showers and Support Resident Choice
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not providing timely bathing for four out of seven sampled residents. Facility policy required that residents receive showers in accordance with their preferences, care plans, and scheduled protocols, with staff responsible for assisting with bathing, performing skin assessments, and documenting these activities. However, documentation and interviews revealed that several residents did not receive showers as scheduled, with significant gaps between showers and incomplete records for October and November. Residents expressed dissatisfaction, noting that they felt unclean and that their preferences for at least weekly or biweekly showers were not honored. One resident with Alzheimer's disease and COPD required substantial assistance with ADLs and was care planned for weekly showers, but records showed only two showers in October and one in November, with a 16-day gap between some showers. Another resident, cognitively intact but needing assistance due to radiculopathy and dementia, was scheduled for weekly showers but experienced a 21-day gap between documented showers. A third resident, also cognitively intact and with a below-the-knee amputation, was care planned for twice-weekly showers but received only two showers in over a month. A fourth resident, recently admitted and with acute and chronic respiratory failure, reported going eleven days before being offered a shower, despite a preference for frequent showers and no care plan or nursing notes documenting bathing. Staff interviews confirmed that showers were often missed due to staffing shortages and lack of a dedicated shower aide. The shower schedule was posted daily, but aides reported difficulty completing showers when short-staffed, and documentation was inconsistent. Leadership acknowledged the issue, noting that the number of completed shower sheets was lower than expected and that improvements were needed. Residents' preferences for bathing were not consistently honored, and documentation of showers and skin assessments was incomplete or missing.
Failure to Timely Destroy and Account for Unused Medications
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the proper storage, destruction, and accountability of medications. During an observation of the medication room, surveyors found the counter space cluttered with a large quantity of unused medications, including medication cards, bottles, bags, and individual doses for 22 residents. Additional medications were found stored in a white bucket above the medication refrigerator. The medications included a variety of prescription drugs such as muscle relaxants, antibiotics, blood pressure medications, and insulin, all of which were no longer in use and awaiting destruction. The facility's policy required unused, contaminated, or expired prescription drugs to be disposed of in accordance with state laws and regulations, and for the destruction process to be witnessed and documented appropriately. Interviews with staff confirmed the ongoing issue. A Certified Medication Tech stated that the medication room was a mess and contained non-narcotic medications that were no longer in use, and that nursing managers were responsible for destroying expired medications. An LPN and the ADON both acknowledged that the medication room was disorganized and full of medications pending destruction, with the ADON noting that it had been several months since the room was clean and orderly. The MDS Coordinator described the room as a disaster that had been in that state for at least a couple of months. The DON admitted that the medication room was currently a mess, with a significant backlog of non-narcotic medications needing destruction, and that the process and paperwork required to address the issue had not been completed due to time constraints. The Interim Administrator also confirmed that the medication room should be kept clean and organized, and that all medications not in use should be destroyed in a timely manner. The facility's failure to maintain a process for the timely destruction of unused medications resulted in a cluttered and disorganized medication room, contrary to facility policy and regulatory requirements.
Controlled substances were diverted through improper ordering and receiving
Penalty
Summary
The facility failed to protect residents from misappropriation of property when controlled substances were ordered, received, and handled in a manner that allowed one staff member to obtain narcotic medications for multiple residents and keep the medication instead of stocking it in the medication cart. The report states that the facility’s policy required safeguards to prevent loss or diversion of controlled substances, immediate recording of delivered medications, and resolution or reporting of any discrepancies in narcotic counts. Instead, the Assistant Director of Nursing (ADON) was involved in creating, signing for, and controlling numerous oxycodone orders for residents, including orders entered under a physician name that was no longer current at the facility. During interview, the Administrator and Corporate RN Liaison stated they found multiple oxycodone 10 mg prescriptions entered into the EMR and then discontinued shortly afterward, and that the medications were never provided to the residents. They stated the ADON had picked up the narcotics from the pharmacy, the narcotics were not received by nursing staff from the pharmacy, and the pills never made it to the facility. The pharmacy records showed repeated dispensing of oxycodone 10 mg, usually 90 tablets at a time, for numerous residents, with the delivery forms signed by the ADON. In several cases, the orders were entered and then discontinued within minutes or hours, often with reasons such as entry error, incorrect entry, or order changed. The affected residents included multiple current residents, such as residents with orders for oxycodone 10 mg for pain, some with no documented discontinue date and others with rapid discontinuation after entry. One resident had an order entered under a physician name that the physician later denied was his signature. Another resident had two separate 90-tablet oxycodone fills documented on the same day, and other residents had repeated fills over time. The pharmacist stated the ADON told the pharmacy that she was in charge of controlled substances because of an investigation on diversion at the facility, that the pharmacy should deliver to her, and that she would meet them at the door or bring prescriptions herself. Staff interviews also described that the ADON had previously controlled the BNDD kit and that narcotic counts were typically done by nursing staff at shift change, but the narcotics involved in these transactions were handled outside the normal receiving process.
Failure to Document and Communicate Resident Code Status
Penalty
Summary
The facility failed to maintain a clear and accessible procedure for documenting and communicating a resident's code status and advance directives, as required by its own policy. For one resident, the code status was not documented in the designated sections of the medical record, including the face sheet, physician orders, and the code status book. During a medical emergency, staff were unable to quickly locate the resident's code status, resulting in a delay in initiating CPR. The resident's admission baseline care plan indicated full code status, but this information was not consistently reflected or easily accessible in other required documentation locations. Multiple staff interviews confirmed that code status information should be available in the resident's chart, on the door, and in the code status book at the nurses' station, with all sources matching. However, staff reported that the Social Services Director (SSD), who was responsible for updating and auditing code status information, had not been in the position for some time, leading to discrepancies and outdated records. The newly hired SSD was in the process of auditing and updating code statuses, but at the time of the incident, the information was not current or consistent across all required locations. During the emergency, the LPN was unable to find the resident's code status after searching the physician orders, face sheet, and code status book, resulting in a delay of approximately five minutes before CPR was initiated. Other staff corroborated the difficulty in locating the code status and the expectation that this information should be readily available and consistent. The lack of clear documentation and communication of the resident's code status directly contributed to the delay in providing appropriate emergency care.
Failure to Notify and Monitor After Resident Fall Resulting in Fracture
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards of practice for a resident who experienced a fall resulting in a fracture. The staff did not notify the resident's family or physician in a timely manner following the fall with possible injury. Documentation of the initial assessment and ongoing fall monitoring, including neurological checks, was not completed as required. The facility also lacked a policy and procedure related to falls, fall documentation, and fall notifications. The resident involved had diagnoses including Alzheimer's disease, muscle weakness, high blood pressure, and respiratory failure, and required supervision and a walker for mobility. After the fall, the resident was found on the floor complaining of pain in the left hip and was assisted back to bed by staff. The LPN on duty did not document a full assessment, including baseline neurological checks, and did not notify the physician or the resident's family at the time of the incident. Vital signs were reportedly obtained but not documented, and the nurse did not initiate required fall monitoring or incident reporting procedures. Subsequent shifts identified the resident's continued pain and loss of independence with mobility, leading to an x-ray that revealed a probable fracture. Only then were the physician and family notified, and the resident was transferred to the hospital. Interviews with staff and leadership confirmed that the expected process for falls was not followed, including assessment, documentation, notification, and monitoring. The deficiency was further compounded by the absence of a facility policy on falls and related documentation.
Failure to Provide Timely Medications and Notify Physicians of Unavailability
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident by not ensuring that ordered medications were available for administration and by failing to notify physicians when medications were unavailable. This resulted in three residents not receiving their prescribed medications as ordered. The facility's own policy required medications to be administered as ordered by the physician and in accordance with professional standards, but this was not followed in these cases. One resident with multiple chronic conditions, including multiple sclerosis, hypothyroidism, and restless legs syndrome, did not receive several medications for multiple days after admission. Documentation showed that doses of pantoprazole, venlafaxine, mirabegron, and ropinirole were not administered due to the drugs not being available. There was no documentation that the physician was notified of these missed doses. The resident reported not refusing any medications and expressed that missing these medications for several days would negatively affect their well-being. Another resident with a history of pulmonary embolism, hypertension, and congestive heart failure also did not receive several ordered medications, including antihypertensives, supplements, and an antifungal, due to unavailability. Again, there was no documentation of physician notification regarding the missed doses. A third resident, who had chronic pain following a leg amputation, did not receive pregabalin for several days because the prescription was not renewed in time and the medication was not available, despite some doses being present in the emergency kit. Staff interviews revealed confusion about the process for obtaining and administering medications from the emergency kit and inconsistent practices regarding physician notification when medications were unavailable.
Failure to Provide and Document Pressure Ulcer Care per Physician Orders
Penalty
Summary
The facility failed to provide pressure ulcer care in accordance with professional standards and its own policies, resulting in the deterioration and infection of wounds for a resident. Staff did not consistently provide wound care as ordered by the physician, with multiple instances where wound treatments were not documented as completed on the Treatment Administration Record (TAR) for both the right heel and right gluteal fold wounds. There was also a lack of documentation explaining missed treatments, and the care plan was not updated to reflect the resident's actual skin breakdown and current wound treatments. The resident involved had significant risk factors, including a history of stroke with left-sided weakness, diabetes with circulatory complications, incontinence, and was admitted with a pressure ulcer. Despite these risks, staff failed to conduct timely and complete wound assessments, did not update the care plan to address new or worsening wounds, and did not ensure that wound care orders from the external wound care provider were entered and followed. The wound care provider's notes indicated periods of wound improvement and deterioration, with changes in wound size, drainage, and the presence of nonviable tissue, but these changes were not consistently addressed by facility staff. Interviews with facility staff, including CNAs, LPNs, the MDS Coordinator, the ADON, and the Administrator, revealed a lack of awareness and communication regarding the resident's wounds, inconsistent documentation practices, and failure to notify the wound care provider of new or worsening wounds. The resident ultimately developed an abscess with purulent drainage requiring hospital transfer and surgical intervention. Throughout the period reviewed, the facility did not maintain accurate and timely wound care records, did not follow physician orders, and did not update the care plan as required.
Failure to Implement Effective Infection Control and Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, as evidenced by multiple staff not performing proper hand hygiene and not following Enhanced Barrier Precautions (EBP) during wound care for three residents. Observations revealed that staff, including LPNs and the MDS Coordinator, did not perform hand hygiene before or after glove changes, after contact with potentially contaminated surfaces, or between different wound care tasks. Supplies such as wound cleanser bottles and dressings were placed on potentially contaminated surfaces without barriers, dropped on the floor and reused, and shared between residents, including those with MRSA, without proper disinfection or dedicated use. For one resident with a history of stroke, diabetes, and MRSA in a buttock wound, staff failed to perform hand hygiene at multiple points during wound care, reused supplies that had fallen on the floor, and returned unused supplies from the resident's room to the general treatment cart. Similar lapses were observed with two other residents, one with diffuse large B-cell lymphoma and surgical wounds, and another with MRSA infection and heart failure. In all cases, EBP signage was missing, PPE carts were not consistently available, and staff did not consistently use gowns and gloves as required for high-contact care activities. Interviews with staff and leadership revealed a lack of training and awareness regarding EBP, with several staff members unable to define EBP or describe when and how to implement it. Staff also reported inconsistent practices regarding the use and disposal of wound care supplies, hand hygiene, and PPE. Facility policies required hand hygiene and the use of PPE, but these were not followed in practice, and there was no evidence of staff education or competency assessment on EBP.
Deficient Food Storage, Preparation, and Sanitation Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, resulting in multiple instances where food was not protected from possible contamination. Observations throughout the day revealed that the chrome surfaces surrounding the water wells of the steam table, the plate warmer, and the lower shelf of the steam table were consistently covered with debris, dried food particles, and dried liquid substances. The trash can lid was also found splattered with dried substances, and a tub of butter was left on the back counter with a spatula covered in butter resting on top. The toaster on the back counter was observed to be covered in crumbs, with the inside containing a layer of crumbs and dried substances on the chrome edging. These unsanitary conditions persisted throughout multiple observations at different times of the day, indicating a lack of thorough cleaning and maintenance of non-food contact surfaces in the kitchen and serving areas. Interviews with staff, including dietary aides, cooks, the Dietary Manager (DM), the Administrator, and the Director of Nursing (DON), confirmed that the responsibility for cleaning the dining room tables, steam table, plate warmer, microwave, toaster, and serving area countertops after each meal was shared among the kitchen staff. However, staff reported difficulty in completing all required cleaning tasks between meals due to limited staffing, with only two kitchen staff working each shift. The facility did not have a policy regarding cleaning the kitchen and/or serving station, and the daily deep cleaning schedule outlined specific tasks for certain days but did not ensure consistent cleanliness after each meal service. Additionally, the facility failed to ensure that condiments kept in the serve-out refrigerator were not expired. Observations showed several condiments in squeeze bottles, such as mustard, mayonnaise, salad dressing, and barbecue sauce, were hand-labeled with use-by dates. Interviews revealed that some kitchen staff were new and not yet in the habit of checking use-by dates on condiments and other food items. Staff were expected to label bottles to be used within seven days and discard contents after that date, but this practice was not consistently followed, leading to the presence of expired condiments in the refrigerator.
Failure to Timely Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to ensure that an allegation of verbal abuse by a staff member toward a resident was reported immediately to facility management and to the State Survey Agency within the required two-hour timeframe. According to the facility's policy, all allegations of abuse, including verbal abuse, must be reported to the administrator and the State Survey Agency no later than two hours after the incident. In this case, a nurse aide witnessed another aide verbally abusing a resident by using profane language and reported the incident to the charge nurse between 10:15 P.M. and 10:20 P.M. However, there was no documentation by the charge nurse regarding the allegation, and no immediate notification was made to the administration or the State Survey Agency as required. The resident involved had a history of age-related physical debility, mild cognitive impairment, and generalized anxiety disorder, and required assistance with daily activities. The resident's care plan indicated communication problems and cognitive loss, necessitating respectful and clear communication from staff. Despite these vulnerabilities, the facility's documentation showed a lack of timely and appropriate response to the reported abuse, with no evidence of staff interviews (other than the accused aide), no summary statement, and no documentation of notifications to the administration, physician, or the resident's family. The online report to the State Survey Agency was not made until the following morning, well beyond the required two-hour window. Interviews with various staff members confirmed their understanding that all abuse allegations should be reported immediately and to the State within two hours. The administrator and DON acknowledged that the incident constituted verbal abuse and should have been reported promptly, and that the charge nurse failed to ensure timely notification and initiation of an investigation.
Failure to Timely and Thoroughly Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to document a timely and thorough investigation into an allegation of verbal abuse involving a resident. A nurse aide reported witnessing another aide enter a resident's room and use profane language, calling the resident derogatory names and instructing them to stop contacting their family. The reporting aide stated that the charge nurse was notified of the incident shortly after it occurred, but there was no immediate initiation of an investigation or documentation of the allegation in the resident's medical record. The resident involved had a history of age-related physical debility, mild cognitive impairment, and generalized anxiety disorder, and required assistance with daily activities. The resident's care plan noted communication problems and cognitive loss, emphasizing the need for respectful staff interactions. Despite these vulnerabilities, the facility's investigation documentation was limited to a single witness statement and unsigned questionnaires from seven residents about their feelings of safety, with no evidence of interviews with other staff or documentation of notifications to administration, the physician, or the resident's family. Interviews with facility staff confirmed that allegations of abuse should be reported immediately and investigated by administration. However, the investigation was delayed because the initial notification to administration was not confirmed, and the investigation did not include comprehensive staff interviews or timely documentation. The administrator and DON acknowledged that the process was not followed as required by facility policy, which mandates immediate reporting and thorough investigation of abuse allegations.
Food Safety and Hygiene Deficiencies
Penalty
Summary
The facility failed to maintain food safety standards by improperly handling clean dishware, which could lead to contamination. Observations revealed that staff stacked wet plastic cups on top of each other, trapping water between them, contrary to the 2022 Food Code and the facility's own policy, which require air drying of dishes before storage. Interviews with dietary aides and the dietary manager confirmed that dishes should be air-dried and not stacked while wet, yet this practice was not followed. Additionally, the facility did not adequately separate dented cans from other canned goods, posing a risk of contamination. Observations showed dented cans of apples stored alongside other cans, despite the facility's policy to set aside and discard dented cans. Interviews with dietary aides and the dietary manager indicated that dented cans should be placed in a separate area and not used, but this procedure was not consistently implemented. Furthermore, the facility did not ensure that staff wore appropriate hair restraints while handling food. A dietary aide was observed wearing a ball cap with hair hanging below it, without a hair net, while preparing and serving food. The facility's policy and the 2013 Food Code require hair to be effectively restrained to prevent contamination. Interviews with staff and the administrator highlighted a misunderstanding about the requirement for hair nets when wearing a ball cap, leading to non-compliance with the hair restraint policy.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and/or their representatives regarding transfers or discharges to the hospital, as required by their policy. This deficiency was identified for three residents out of a sample of 18, with a facility census of 51. The facility's policy, revised in December 2016, mandates that details of a transfer or discharge be documented in the medical record and communicated to the receiving healthcare provider, and that appropriate notice be provided to the resident and/or legal representative. For Resident #3, multiple instances were noted where the resident was transferred to the hospital due to issues with a feeding tube, but there was no documentation of written notification provided to the resident or their representative. Similarly, Resident #4 was transferred to the hospital on two occasions due to health concerns, but again, there was no documentation of written notification. Resident #30 was also transferred to the hospital without documented written notification to the resident or their representative. Interviews with facility staff, including an LPN, the Social Service Director, the Director of Nursing, the Administrator, and the Director of Operations, revealed a lack of awareness and practice regarding the provision of transfer forms to residents and/or their representatives. The staff did not make copies of the transfer forms, and there was no system in place to ensure that residents or their representatives received the necessary documentation during transfers to the hospital.
Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed-hold policy to residents or their representatives upon transfer to a hospital, as required by their own policy. This deficiency was identified for three residents who were transferred to the hospital for various medical reasons. The facility's policy mandates that residents or their representatives be informed in writing about the bed-hold policy prior to any transfers or therapeutic leaves, but this was not documented for the residents in question. Resident #3, who had diagnoses including acute kidney failure and schizophrenia, was transferred multiple times to the hospital due to issues with a feeding tube and other medical concerns. Despite these transfers, there was no documentation indicating that the resident or their representative received written information about the bed-hold policy. Similarly, Resident #4, who had mild cognitive impairment, was transferred to the hospital twice due to severe stomach pain and other symptoms, but again, there was no documentation of the bed-hold policy being provided. Resident #30, with conditions such as COPD and diabetes, was also transferred to the hospital without receiving the required bed-hold policy documentation. Interviews with facility staff, including the LPN, Social Service Director (SSD), Director of Nursing (DON), and Administrator, revealed a lack of awareness and training regarding the requirement to provide the bed-hold policy upon resident transfer. The SSD admitted to not sending the bed-hold policy to residents or their representatives and was unaware of this requirement until reviewing the policy. The DON and Administrator confirmed that the policy was not being sent as required, indicating a systemic issue in the facility's adherence to its own policies.
Sanitation Deficiency in Kitchen and Dining Areas
Penalty
Summary
The facility staff failed to maintain a sanitary and comfortable environment in the kitchen and dining areas, as evidenced by the presence of dead bugs in the light fixtures. Observations conducted on two separate occasions revealed several dead bugs in lights located just before entering the kitchen, above the refrigerator and freezer, and at the entrance of the kitchen. The facility did not have a policy regarding the maintenance of light fixtures, which contributed to the oversight. Interviews with various staff members, including dietary aides, the dietary manager, the maintenance director, and the administrator, highlighted a lack of communication and awareness regarding the issue. Dietary aides indicated that maintenance was responsible for cleaning the lights, but they were unsure of the frequency of cleaning. The dietary manager and maintenance director both stated that maintenance was responsible for the lights, with a monthly checklist in place, but neither was aware of the dead bugs. The administrator confirmed that maintenance was responsible and that kitchen staff should report issues in a requisition book, indicating a breakdown in the reporting and maintenance process.
Failure to Monitor Medication Parameters for a Resident
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs due to inadequate monitoring of diltiazem administration. The resident, who had diagnoses including cognitive communication deficit, bradycardia, and Parkinson's disease, was prescribed diltiazem with specific parameters to hold the medication if the systolic blood pressure was below 110 mmHg. Despite this, the medication was administered on multiple occasions when the resident's blood pressure was below the prescribed threshold, as documented by a Certified Medication Technician (CMT). This failure to adhere to the physician's orders was confirmed through interviews with the Licensed Practical Nurse (LPN), the CMT, the Director of Nursing (DON), and the Administrator, all of whom acknowledged the importance of following the medication parameters. The resident's care plan highlighted the risk of adverse reactions due to the variety of medications being administered, and the need for staff to administer medications as ordered. However, the staff did not comply with the order to hold diltiazem when the resident's blood pressure was below the specified level, potentially risking further hypotension. The DON and Administrator both expressed that they expected staff to follow physician orders and acknowledged that the medication should not have been administered when the resident's blood pressure was out of parameters.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility staff failed to ensure that all residents were free from significant medication errors when a Licensed Practical Nurse (LPN) did not prime an insulin pen before administering insulin to a resident. The resident, who was cognitively intact, had a medical history that included chronic obstructive pulmonary disease, high blood pressure, peripheral vascular disease, and diabetes. The resident's physician had ordered Novolog insulin to be administered subcutaneously with meals, and the resident's blood sugar level was recorded at 305 mg/dL before the insulin was administered. However, the LPN did not follow the manufacturer's instructions to prime the insulin pen, which involves selecting two units, tapping the cartridge to collect air bubbles, and ensuring a drop of insulin appears at the needle tip before administration. Interviews with facility staff revealed inconsistencies in the understanding and practice of priming insulin pens. The LPN involved in the incident believed that the pens were pre-dosed and pre-primed, and therefore did not require priming. In contrast, another LPN stated that they always prime insulin pens before use, and the Director of Nursing (DON) confirmed that staff are trained to prime insulin pens with two units of insulin before each use. The DON also stated that this training is provided upon hire and annually. The facility's policies on insulin administration and medication administration did not address the need to prime insulin pens, despite the manufacturer's instructions indicating its necessity.
Ineffective Pest Control Program Leads to Gnat Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of multiple gnats in a room shared by two residents. One resident, who had no cognitive impairment, reported that the other resident, who had severe cognitive impairment, left food and cups in the room, attracting gnats. Observations over several days confirmed the presence of gnats around food items and cups in the room, with staff acknowledging the issue but not effectively addressing it. Interviews with various staff members, including a CNA, housekeeper, CMT, RN, and the Maintenance Director, revealed that the presence of gnats was known, particularly in the room of the resident with severe cognitive impairment. Staff reported attempts to manage the situation by picking up food and cups, and a pest control company was mentioned as spraying the facility. However, the Maintenance Director was not aware of the issue until recently and had only taken limited actions, such as installing plug-in devices in some rooms. The Administrator was unaware of the gnat problem in the specific room until it was brought to her attention during an observation. She stated that staff should report such issues to maintenance or administrative staff. Despite some efforts to address the problem, such as cleaning specific rooms and using pest control measures, the facility's actions were insufficient to prevent the ongoing presence of gnats in the residents' room.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 126 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Marshfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Webco Manor | 1.4 mi | ★★★★★ | 5 | 0 |
| Strafford Care Center | 12.4 mi | ★★★★★ | 19 | 0 |
| Glenwood Healthcare | 14.4 mi | ★★★★★ | 0 | 0 |
| Copper Rock Healthcare | 19 mi | ★★★★★ | 1 | 0 |
| Glendale Gardens Nursing & Rehab | 20.1 mi | ★★★★★ | 15 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.