Average — CMS composite of the measures below.
The next survey window likely opens 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 Marion Pointe during CMS and state inspections, most recent first.
Food storage and kitchen sanitation deficiencies were identified when surveyors found opened dry goods that were not dated, a dirty refrigerator with food crumbs and liquids inside, and frozen meats that were opened, unlabeled, and undated. Surveyors also observed dust and debris on the wall and overhead piping support near the food prep area, and the DM verified the conditions.
Advance directive records were inconsistent for a resident with severe cognitive impairment and diagnoses including cerebrovascular disease, hypertensive heart disease, major depressive disorder, and vascular dementia. The paper chart contained a DNR order as the first document in the advance directives section, while the EMR listed the resident as full code; another full code form was also present in the paper chart. An LPN confirmed the mismatch, and SS stated code status paperwork should be updated when changes occur. The resident stated a preference to be full code.
Facility Failed to Maintain Required Resident Room Temperatures: Three residents were found in rooms below the required temperature range, and the 200 hallway felt cold. Two residents with impaired cognition and dependence for ADLs reported cold bedrooms, and a third resident with intact cognition said he had already reported the issue and was wearing multiple layers of clothing. Maintenance staff verified room temperatures of 69.4, 69.7, and 69.8 degrees F, below the stated 71 to 81 degrees F range.
Failure to document and treat injury after a fall: A resident with dementia, abnormal gait, repeated falls, and poor safety awareness was found on the floor next to the bed after trying to walk to the bathroom and not seeing a wheelchair blocking the path. The resident sustained an abrasion/skin tear above the right eye, but no skin assessment documented the injury and there was no treatment plan for the fall-related head injury; the DON confirmed the gap in follow-up care.
Improper Medication Storage and Unauthorized Self-Administration: A resident with impaired cognition, dementia, and moderate ADL needs had Nystatin cream left in a medication cup on the bed. The resident said he received the fungus cream every day, and an LPN confirmed the substance was his Nystatin cream. The resident had no order to self-administer, the TAR did not show the cream was signed out, and the DON confirmed there was no self-administration order.
The facility failed to provide ordered therapeutic diets as prescribed for three residents. Two residents with dysphagia and mechanically altered diet needs were served pureed foods prepared with unmeasured liquids, and the dietary manager verified the portions were smaller than ordered. Another resident with Huntington's disease and dysphagia was observed with thin water at bedside despite an order for nectar thick liquids and strict supervision, and the DON confirmed the ordered liquid consistency.
Failure to document a topical medication in the TAR occurred for a resident with impaired cognition, dementia, CKD, and a prior femur fracture. The resident had an order for Nystatin cream PRN for red areas, but the TAR did not show it was administered. During observation, the resident had a cup containing the cream mixed with water, stated staff gave it to him every day, and an LPN said the resident was allowed to self-administer even though there was no order for self-administration; the DON confirmed the medication was not signed out in the TAR.
Surveyors found that food items, including fudge rounds and cereal, were stored directly on the floor in the kitchen dry storage area, and several bags of food in the freezer were open and not labeled or dated. Dietary staff confirmed these storage and labeling issues, which were not in accordance with the facility's food storage policy.
A resident with cognitive and physical impairments, who expressed strong interest in reading materials and other activities, was not provided with books, magazines, or opportunities to participate in preferred activities. The care plan lacked documentation for activity provision or reasons for the resident remaining in bed, and staff did not facilitate engagement despite the resident's stated willingness to participate.
A resident with cognitive impairment and frequent incontinence was left in visibly wet clothing for over an hour without staff intervention, despite a care plan requiring checks every two hours. Staff were not observed providing care until the DON was notified, and the resident reported similar delays in care during interviews.
The facility failed to maintain a sanitary environment in the kitchen's dry storage area, with mouse droppings and urine found on various food products. Despite efforts to address the issue, the problem persisted, and the dietary staff did not effectively communicate the issue to housekeeping. The facility's policies on sanitation and food storage were not followed.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to properly store, label, and date food in the kitchen, and failed to maintain the kitchen in a sanitary manner. During observation of dry storage, surveyors found an opened, undated bag of oats and honey granola, an opened, undated bag of pasta noodles, and an opened, undated loaf of bread. The Dietary Manager verified that the granola, pasta, and bread had been opened and were not dated. In reach-in refrigerator #1, surveyors observed the inside coated with unidentifiable liquids and food crumbs. The refrigerator also contained an opened, undated bottle of barbeque sauce, an opened, undated bag of mozzarella, an opened, undated bottle of cranberry juice, and opened, undated bottles of thickened apple juice and orange juice. The Dietary Manager verified the refrigerator was dirty and the items were opened and undated. In reach-in freezer #1, surveyors found opened, unlabeled, and undated bags of breaded pork patties, chicken breasts, and sausage links, which a Dietary Aide verified. Surveyors also observed dust and debris coating the wall and metal support for overhead piping above two coffee pots and near the food preparation area, and the Dietary Manager verified this condition. The facility policy stated food storage areas should always be clean and opened food should be labeled and dated.
Advance Directive Records Were Inconsistent
Penalty
Summary
The facility failed to ensure a clear advance directive and failed to ensure the advance directive in the electronic medical record (EMR) matched the paper chart for one resident. The resident had been admitted on 09/25/24 and had diagnoses including cerebrovascular disease, hypertensive heart disease without heart failure, major depressive disorder, and vascular dementia. The annual MDS assessment indicated severe cognitive impairment, and the care plan stated the resident and/or responsible party had chosen full code status, with interventions to call emergency services if needed and to discuss advance directives and code status quarterly and as needed. Observation of the paper chart revealed that the first document under the advance directives tab was a DNR order signed by the physician, while another document in the chart was a full code form signed by the resident. The EMR identified the resident as full code. An LPN confirmed the discrepancy between the DNR document in the paper chart and the full code status in the EMR. Social Services stated that when a resident's code status changes, the EMR and paper chart are updated and the previous code status paperwork is removed from the paper chart. The resident stated a preference to be full code.
Facility Failed to Maintain Required Resident Room Temperatures
Penalty
Summary
The facility failed to ensure the temperature inside the building remained between 71 and 81 degrees Fahrenheit. During observation, the 200 hallway felt cold, and three residents reviewed for facility temperature were found in rooms below the required range. Resident #9, admitted with diagnoses including epilepsy, dementia with mood disturbances, major depressive disorder, and anxiety disorder, had moderately impaired cognition and was dependent for toilet hygiene, personal hygiene, and shower hygiene. He stated his bedroom was cold, and Maintenance Assistant #214 verified the room temperature was 69.4 degrees Fahrenheit. Resident #10, admitted with diagnoses including hyperlipidemia, quadriplegia, apraxia, major depressive disorder, and obstructive sleep apnea, also had moderately impaired cognition and was dependent for personal hygiene, toilet hygiene, and all mobility. He stated his bedroom was cold, and Maintenance Assistant #214 verified the room temperature was 69.7 degrees Fahrenheit. Resident #33, admitted with diagnoses including Alzheimer's disease, hyperlipidemia, hypertension, and type two diabetes mellitus, had intact cognition and was independent for mobility. He reported that his room was cold and that he had told the facility, stating he had to wear multiple layers of clothing because of the temperature. Maintenance Assistant #214 verified Resident #33's room was 69.8 degrees Fahrenheit, and staff confirmed the building temperature should be maintained between 71 and 81 degrees Fahrenheit.
Failure to Document and Treat Injury After a Fall
Penalty
Summary
The facility failed to comprehensively treat a resident after a fall. Resident #27 was admitted with diagnoses including Alzheimer's disease with late onset, unspecified protein-calorie malnutrition, dementia with moderate mood disturbance and agitation, anxiety, psychotic disorder with delusions, glaucoma, hypertension, muscle weakness, abnormal gait and mobility, repeated falls, and personal injury in an unspecified motor-vehicle accident. The resident's care plan identified fall risk related to confusion from the dementia process, impaired balance and mobility, non-compliance with mobility aids, poor coordination, unsteady gait, psychotropic medication use, poor safety awareness, and non-compliance with fall interventions. The care plan also identified an actual and potential alteration in skin integrity related to incontinence, poor oral intake, and non-compliance with interventions. After the resident was found on the floor next to the bed, between the bed and wheelchair, staff documented that the resident had been trying to walk to the bathroom and did not see the wheelchair obstructing the pathway. The resident sustained an abrasion above the right eye, denied headache, head pain, and vision changes, and was assisted to the bathroom and back to bed. The provider and emergency contact were notified later that evening, and the next morning the resident was noted to be on neurological checks with a skin tear above the right eye and no complaints of pain or discomfort. However, no skin assessment was completed documenting the skin tear to the right eyebrow, and the Interim DON confirmed there was no treatment plan regarding the fall and injury above the right eye. Facility policy stated nurses shall assess and document recent injury, especially fracture or head injury, and follow up on any fall with associated injury.
Improper Medication Storage and Unauthorized Self-Administration
Penalty
Summary
The facility failed to properly store medication in a safe manner for one resident reviewed for medication storage. Resident #15 had an admission and readmission, with diagnoses including displaced intertrochanteric fracture of the left femur, chronic kidney disease, and dementia. The quarterly MDS showed impaired cognition and the resident required moderate assistance with ADLs. The care plan noted the resident preferred to provide his own personal care and was resistant to staff assistance, and the Self Medication Program Assessment of Skills stated he presented a danger to himself or others while self-administering medication and was not a candidate for the self-medication program. The physician order for Nystatin External Cream was to apply it to red areas topically every 12 hours as needed, but the TAR showed the cream had not been signed out. During observation, the resident was sitting in a recliner with a medication cup containing an unknown substance mixed with water on the bed. The resident identified the substance as his fungus cream and stated they give it to him every day. An LPN confirmed the substance was the resident's Nystatin cream and stated the resident was allowed to self-administer the medication per the doctor, although there was no order for self-administration. The DON confirmed the resident did not have an order to self-administer and that the Nystatin cream had not been signed out in the TAR. The facility policy stated residents may self-administer medications only if the attending physician and interdisciplinary care planning team determine they can do so safely.
Incorrect Portions and Unthickened Liquids Served
Penalty
Summary
The facility failed to ensure residents received the correct portions during meal service and failed to ensure liquids were thickened according to physician orders. The deficiency involved three residents identified in the report, all of whom had diets ordered to match their nutritional and swallowing needs. Facility records, observation, and staff interviews showed that the food served and prepared did not consistently match the ordered therapeutic diets. Two residents had physician orders for a regular diet with pureed texture and thin liquids, while their MDS assessments and care plans indicated a mechanically altered diet was required. During lunch meal preparation, a dietary aide pureed green beans and deli turkey using unmeasured amounts of water and gravy. The dietary manager verified the resulting portions were less than the ordered serving sizes, including green beans measuring slightly more than half of a half cup and turkey not completely filling one third cup. The dietician stated the facility should follow the menu and serving sizes and noted that incorrect portion sizes could affect residents' nutritional intake. A third resident had diagnoses including Huntington's disease, anorexia, and dysphagia, and was ordered a mechanical soft diet with nectar thickened liquids and strict supervision with all oral intake. The resident's care plan and speech therapy evaluation also reflected the need for thickened liquids. However, a water pitcher containing thin water was observed on the resident's bedside table, and a CNA confirmed the liquid was not nectar thick. The DON also confirmed the resident was to receive nectar thickened liquids with total supervision due to aspiration potential. The facility policy stated therapeutic diets should match what residents are receiving.
Failure to Document Topical Medication in TAR
Penalty
Summary
The facility failed to ensure medications were documented in the Treatment Administration Record (TAR) for one resident (#15) reviewed for medication administration. Resident #15 was admitted and later readmitted with diagnoses including displaced intertrochanteric fracture of the left femur, chronic kidney disease, and dementia. The quarterly MDS dated 09/25/25 showed impaired cognition and that the resident required moderate assistance with ADLs. The care plan noted the resident preferred to provide his own personal care and was resistant to staff assistance, and the Self Medication Program Assessment of Skills dated 09/30/25 stated the resident was a danger to himself or others while self-administering medication and was not a candidate for the self-medication program. The physician order dated 02/28/25 included Nystatin External Cream 100,000 units/gram to be applied to red areas topically every 12 hours as needed. Review of the TAR for 12/2025 showed the Nystatin External Cream had not been documented as received. During observation on 02/09/25, the resident was seen sitting in a recliner with a medication cup containing an unknown substance mixed with water on the bed. The resident stated the substance was his fungus cream and that staff gave it to him every day. An LPN identified the substance as the resident’s Nystatin cream and stated the resident was allowed to self-administer the medication per the doctor, but confirmed there were no orders for self-administration. The DON also confirmed the resident did not have an order to self-administer and that the Nystatin cream had not been signed out in the TAR.
Improper Food Storage and Labeling in Kitchen and Freezer
Penalty
Summary
Surveyors observed that food was not stored in a sanitary manner in the facility's kitchen dry storage and freezer areas. Specifically, a case of fudge rounds and four plastic grocery bags containing fruit-flavored cereal were found stored directly on the floor in the dry storage area. In the reach-in freezer, seven bags of unidentified food products were found open and not dated. During an interview, dietary staff confirmed that the bags in the freezer contained various types of meat and vegetables, and acknowledged that these items were not labeled or dated when opened. The staff also verified the improper storage of the fudge rounds and cereal on the floor. Review of the facility's food receiving and storage policy indicated that food should be raised off the floor and that all foods stored in the refrigerator or freezer should be covered, labeled, and dated.
Failure to Provide Individualized Activities for Bedbound Resident
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including moderate cognitive impairment, major depressive disorder, schizoaffective disorder, and significant physical limitations, was not provided with activities tailored to her interests and needs. The resident's Minimum Data Set (MDS) assessment indicated that it was very important for her to have access to books, newspapers, magazines, be around animals, and participate in religious services, with some interest in music and keeping up with the news. Despite these documented preferences, there was no care plan addressing activities for the resident, nor any documentation explaining why she remained in bed or was not provided with the requested materials. The resident was dependent on staff for most activities of daily living and wheelchair mobility, yet staff only used a mechanical lift to weigh her and did not facilitate her participation in activities. During interviews and observations, the resident expressed a desire to get out of bed and participate in activities, stating she would be willing to use her wheelchair despite feeling scared. She also reported that the facility did not bring her any books, magazines, or other items to engage her while she was bedbound. The administrator confirmed there was no documentation regarding the resident's activity participation, reasons for her being in bed, or any refusals to get out of bed. The lack of individualized activity provision and documentation directly contradicted the resident's assessed preferences and needs.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a dependent resident with a history of cerebrovascular disease, psychotic disorder with delusions, vascular dementia, and major depressive disorder was not provided timely incontinence care. The resident, who was assessed as frequently incontinent of bowel and bladder and required assistance every two hours per their care plan, was observed sitting in visibly wet sweatpants in their wheelchair for over an hour. During this period, no staff were observed providing care or conducting room-to-room checks, and the resident's room developed a musty odor. Staff only attended to the resident after the issue was brought to the attention of the Director of Nursing by the surveyor. Interviews with the resident confirmed that second shift staff sometimes left them in a wet bed or brief for extended periods, sometimes up to an hour or more before being changed. The Director of Nursing verified the resident's condition and the musty smell in the room. Review of facility policy indicated that residents unable to perform activities of daily living independently should receive necessary services to maintain hygiene, but this was not followed in the observed instance.
Sanitation Deficiency in Kitchen Storage Area
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the dry storage room of the kitchen, which had the potential to affect all residents receiving food from the kitchen. During an observation, mouse droppings and urine were found in a box of thickened orange juice and throughout the storage area, including on food products such as ketchup packets, lasagna noodles, peanut butter tubs, soda cans, and chocolate sprinkles. Some food items, like French-fried onions and various noodles, were chewed through and opened without being dated. Interviews with dietary staff revealed that the facility had been actively working on eliminating the mice, but the problem persisted. Dietary staff confirmed the presence of mouse droppings and urine and acknowledged that chewed food products would be discarded. The dietary supervisor noted that despite efforts to clean the area, the droppings and urine reappeared within days. The administrator expressed frustration with the dietary staff's failure to communicate the cleanliness issue to the appropriate personnel, despite having a capable housekeeping staff. The facility's policies on sanitation and food storage emphasized cleanliness and protection from rodents, which were not adhered to in this instance.
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.
Illustrative
What surveyors actually found near you
We read the 255 citations issued within 25 miles in the last 12 months — including the 1 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.
Illustrative
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.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Marion
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harding Pointe | 0.5 mi | ★★★★★ | 19 | 0 |
| Marion Nursing & Rehab | 1.4 mi | ★★★★★ | 22 | 0 |
| Marion Valley Post Acute | 1.7 mi | ★★★★★ | 7 | 0 |
| Presidential Post-acute | 2.7 mi | ★★★★★ | 19 | 1 |
| Meadows Of Marion Health And Rehabilitation The | 2.7 mi | — | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Marion Pointe.
100% money-back within 48 hours.
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.