Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Marion Valley Post Acute during CMS and state inspections, most recent first.
Surveyors found that the facility’s high‑temperature dishwasher was not consistently reaching manufacturer‑required temperatures or completing proper rinse cycles for dish sanitation. Observations showed that during operation, only the wash gauge changed while the pump rinse and final rinse cycles did not engage, and subsequent checks revealed final rinse temperatures below the specified minimum. Review of several months of dish machine logs showed multiple instances of substandard final rinse temperatures, despite facility policies requiring dishwashing to meet temperature and sanitation standards and to follow manufacturer instructions.
A resident with multiple serious diagnoses had a care plan and physician orders reflecting a DNRCCA code status, but the signed advance directive was never scanned into the electronic record as required. Although the transfer form listed the resident as DNRCCA, there was no signed code status form available in the electronic system, and an LPN could not locate the paperwork when sending the resident to the ED. The DON confirmed the DNRCCA document was not scanned into PCC, contrary to facility policy requiring advance directives to be maintained in a consistent, readily retrievable section of the medical record.
A dependent, cognitively impaired resident with multiple comorbidities was found on the floor of her room, after which family, the CNP, and the DON were notified and x‑rays were obtained that initially showed no fractures despite ongoing pain. Subsequent imaging revealed a cortical breach of the femoral neck and later a CT confirmed a nondisplaced right intertrochanteric femur fracture, with the DON unable to determine whether it was related to the fall or occurred during routine care and acknowledging it was an injury of unknown origin. The DON confirmed that no Facility‑Reported Incident was completed, no investigation into the injury of unknown origin was conducted, and the event was not reported to the State Agency as required by facility policy and federal regulations.
A resident with moderate cognitive impairment, multiple chronic conditions, and total dependence on staff for mobility and ADLs was found on the floor and subsequently had multiple negative x‑rays of the right arm, leg, and hip despite ongoing pain. A later hip x‑ray showed a cortical breach and recommended a CT, and a subsequent CT revealed a nondisplaced right intertrochanteric femur fracture of unknown origin. The DON could not determine whether the fracture was related to the fall or occurred during routine care and acknowledged that no Facility‑Reported Incident was completed, no investigation into the injury of unknown origin was conducted, and the event was not reported to the State Agency, despite facility policy requiring identification, investigation, and reporting of possible abuse, neglect, or mistreatment.
A resident admitted with stage 2 and stage 3 heel pressure ulcers had physician orders for detailed wound care to the right heel, offloading of the right foot in bed, and use of a heelless shoe while ambulating. The comprehensive care plan identified risk for pressure ulcers and documented only the left heel wound, with general skin and pressure-relief interventions such as hydration monitoring, daily skin checks, pressure redistribution surfaces, and weekly nurse skin assessments. The care plan did not include the right heel pressure ulcer or the ordered interventions for offloading and heelless shoe use, which the DON confirmed were absent, contrary to facility policy requiring comprehensive, person-centered care plans for all identified conditions.
Two residents did not receive fully documented skin and wound care as ordered and required by facility policy. One resident admitted with multiple skin issues and a wound vac had admission nursing evaluations that noted the need for wound care but lacked comprehensive skin assessments, including missing wound locations, descriptions, and measurements, despite later documentation of a surgical wound to the right trochanter. Another resident with vascular disease, diabetes, CHF, and a left AKA had multiple wounds and a wound vac, with physician orders for specific nightly wound treatments and scheduled wound vac dressing changes and settings; however, the March TAR showed missing entries for wound care and wound vac management on several dates, and the DON confirmed there was no documentation that these treatments were completed.
A resident with moderate cognitive impairment, hemiplegia, and dependence on staff for bed mobility and incontinence care was left on her side on a low air loss mattress while a CNA left the room alone to obtain linen, with the bed remaining at waist height. When the CNA returned, the resident had fallen from the bed to the floor and later reported pain in her right arm and leg. The DON confirmed the resident required two‑person assistance for bed mobility and incontinence care, and that only one CNA was present and had left the resident unattended, leading to the fall.
Crash carts were not routinely inspected or properly maintained, with missing equipment, incomplete documentation, and inconsistent checks by nursing staff. Required items were not always present or verified, and staff interviews confirmed that inspection protocols were not followed, potentially affecting all residents identified as Full Code.
A resident with severe cognitive impairment and multiple diagnoses did not have required fall prevention interventions in place, such as non-skid materials on the bed and in the Broda chair, as specified in the care plan. Observation and staff interview confirmed these interventions were missing, contrary to facility policy.
The facility failed to maintain a clean and sanitary kitchen, potentially affecting all residents receiving food and beverages. A family member reported unsanitary conditions, and an observation revealed a water-damaged, cracked, and bowing ceiling tile behind the tray line. A dietary aide confirmed the tile sometimes leaked when it rained, and the Dietary Director acknowledged the leak but had not seen it actively leaking. The facility's policy required the Dining Services Director to ensure kitchen cleanliness.
The facility failed to ensure proper hand hygiene during lunch meal service, affecting 113 residents. Observations revealed that two cooks handled food and kitchen items without changing gloves or performing hand hygiene, contrary to the facility's policy.
Failure to Maintain High-Temperature Dishwasher per Manufacturer Standards
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its high‑temperature dishwasher operated at manufacturer‑required temperatures and cycles for proper sanitation of dishware and utensils. Surveyor observations showed that the dishwasher’s posted minimums were a wash cycle of 159°F, pump rinse of 160°F, and final rinse of 180°F at 20 psi. When the machine was observed running, the wash gauge moved to 162°F, but the pump rinse and final rinse gauges did not move, and the machine did not activate the pump rinse or final rinse cycles while trays were conveyed through. Multiple trays were observed passing through the dishwasher without the rinse cycles engaging. The dietary manager confirmed that while water was spraying continuously inside the machine, the rinse cycles did not start as expected and that the dishwasher was a high‑temperature machine. On a follow‑up observation the next day, while the dishwasher was idle, the gauges read 164°F for wash, 162°F for pump rinse, and 120°F for final rinse. When the dishwasher was run, the wash gauge read 150°F, the pump rinse 160°F, and the final rinse 170°F over five cycles, which did not meet the manufacturer’s specified minimums of 150°F wash, 160°F pumped rinse, and 180°F final sanitizing rinse at 20 psi. The maintenance director and dietary manager verified that the dishwasher was not washing or rinsing dishes per manufacturer recommendations. Review of the dishwasher temperature logs for the previous four months showed multiple days when the final rinse temperatures did not meet the required minimums. Facility policies required that dishwashing meet temperature and sanitation standards and that dishwashing machines be operated according to manufacturer instructions, but the recorded temperatures and observed operation did not comply with these standards.
Failure to Maintain Accessible DNRCCA Documentation in Medical Record
Penalty
Summary
The facility failed to ensure that a resident’s documented code status and advance directive paperwork were maintained and readily accessible in the medical record as required by policy. Former Resident #116 was admitted with serious medical conditions including sepsis due to enterococcus, acute and subacute infective endocarditis, bacteremia, urinary tract infection, and acute pulmonary edema. The resident’s care plan, initiated on 11/12/25, identified an advance directive of Do Not Resuscitate Comfort Care Arrest (DNRCCA), and physician orders consistently reflected a DNRCCA code status from admission through discharge. The care plan also specified that the resident’s code status would be in the medical record at all times. Despite this, review of the electronic medical record (PCC) showed that no DNRCCA advance directive document was scanned into the system from admission through discharge. The eInteract hospital transfer form completed on 01/09/26 listed the resident’s code status as DNRCCA, but there was no signed code status form on file in the electronic record. During interview, the DON stated that the DNRCCA paperwork for this resident was in medical records but acknowledged it had not been scanned into PCC, leaving nurses without electronic access to the document. In a separate interview, an LPN reported being unable to locate the DNRCCA paperwork when preparing to send the resident to the emergency department. Facility policy on Advance Directives required that copies of any executed advance directives be obtained, maintained in the same section of the medical record, and be readily retrievable by staff, which was not met in this case.
Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an injury of unknown origin to the State Agency as required by its abuse, neglect, exploitation, and misappropriation prevention policy and federal requirements. A resident with COPD, anxiety, diabetes mellitus, hypertension, and unspecified hemiplegia, who had moderate cognitive impairment and was dependent on staff for toilet hygiene, bed mobility, transfers, and bathing, was found on the floor of her room with her back on the floor and head against the bedside stand. Following this fall, the nurse notified the resident’s family, CNP, and DON, and x‑rays were ordered. Initial x‑rays of the right arm and leg, and a subsequent right hip x‑ray, were negative for fracture, though they showed diffuse osteopenia. Further imaging on a later date showed a cortical breach with a small step deformity of the femoral neck on the right hip, and a CT scan later confirmed a nondisplaced right intertrochanteric femur fracture. The DON stated that multiple x‑rays were done after the fall because of continued complaints of pain, that the resident initially refused a CT scan which was then rescheduled, and that the CT ultimately showed the fracture. The DON also stated the facility did not believe the fracture occurred from the original fall but could not identify the cause, acknowledged the resident was dependent on staff for all transfers, toileting, and bed mobility, and could not say if the fracture occurred during routine care. The DON confirmed that, despite the fracture being an injury of unknown origin, the facility did not complete a Facility‑Reported Incident, did not conduct an investigation into the injury of unknown origin, and did not report it to the State Agency when it was identified, contrary to facility policy requiring identification, investigation, and reporting of all possible incidents of abuse, neglect, or mistreatment within required timeframes.
Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to investigate an injury of unknown origin for one resident who was dependent on staff for toilet hygiene, bed mobility, transfers, and bathing, and who had moderate cognitive impairment and multiple medical diagnoses including COPD, anxiety, diabetes, hypertension, and unspecified hemiplegia. The resident was found on the bedroom floor with her back on the floor and head against the bedside stand, and the family, CNP, and DON were notified, with x‑rays ordered. Initial x‑rays of the right arm, leg, and hip were negative for fracture, and a subsequent hip x‑ray also showed no fracture. A later x‑ray of the right hip with unilateral pelvis showed a cortical breach with a small step deformity of the femoral neck and recommended a CT scan for further evaluation. A CT scan of the right hip later revealed a nondisplaced right intertrochanteric femur fracture. The DON stated that multiple x‑rays were done after the fall because of continued complaints of pain and that all were negative for fractures until the later imaging, and also stated that the resident refused the initially scheduled CT scan and it was rescheduled. The DON reported that the facility did not believe the fracture occurred from the original fall but could not identify what caused the fracture, acknowledged that the resident was dependent on staff for all transfers, toileting, and bed mobility, and could not say if the fracture was caused during routine care. The DON confirmed that, despite the fracture being identified and its cause being unknown, the facility did not complete a Facility‑Reported Incident, did not conduct an investigation into the injury of unknown origin, and did not report the injury of unknown origin to the State Agency, contrary to the facility’s abuse, neglect, and exploitation policy requiring identification, investigation, and reporting of all possible incidents within required timeframes.
Failure to Include All Pressure Ulcers and Interventions in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that included all of a resident's skin issues and associated interventions. A resident admitted with diagnoses including a stage 2 pressure ulcer of the left heel and a stage 3 pressure ulcer of the right heel had physician orders in place for specific wound care to the right heel, including cleansing with normal saline, applying a betadine wet-to-dry sterile dressing, covering with an ABD pad, wrapping with kerlix, and applying betadine only to the wound area. Additional orders included applying antibiotic cream and a Band-Aid to the left heel daily, offloading the right foot at all times while in bed, and using a heelless shoe on the right foot while ambulating. Review of the resident’s care plan, dated the same day as admission, showed the resident was identified as being at risk for pressure ulcers and other skin problems related to decreased mobility and diabetes, and it documented a wound to the left heel. Interventions listed included monitoring hydration every shift, monitoring skin daily with routine care, using a pressure redistribution cushion in the wheelchair, a pressure redistribution mattress on the bed, and completing weekly skin assessments by a nurse. However, the care plan did not include the right heel pressure ulcer or the specific interventions for offloading the right foot and use of the heelless shoe. In an interview, the DON confirmed that there was no care plan addressing the right heel pressure ulcer or these related interventions, despite facility policy requiring comprehensive, person-centered care plans with measurable objectives and services for identified problem areas and conditions.
Failure to Complete Admission Skin Assessments and Follow Wound Care Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and care according to physician orders and facility policy for skin and wound management. For one resident admitted with multiple skin issues and a wound vac, the nursing admission evaluation documented that the resident was admitted for wound care and had multiple skin issues, but did not include the location, description, or measurements of the wounds. Subsequent documentation showed a surgical wound to the front right trochanter with specific measurements, and later entries alternately indicated no skin issues or that the surgical site was present on admission, but there was no comprehensive admission skin assessment with required details. The DON confirmed that the medical record lacked documentation of comprehensive wound assessments upon both admission dates, despite the expectation that staff complete such assessments including wound location, description, and measurements. A second resident with diagnoses including peripheral vascular disease, diabetes mellitus, congestive heart failure, and a history of left above-knee amputation had multiple wounds documented on a wound assessment, including a surgical site on the right fifth toe, a deep tissue injury pressure ulcer on the right heel, and a surgical site on the left lateral thigh, all present upon readmission. Physician orders directed specific wound care to the right fifth toe surgical site and right heel wound every night shift, and wound vac dressing changes three times weekly, with continuous wound vac therapy at a specified pressure setting to the left AKA bridged to the left lateral thigh. These orders required cleansing with normal saline, application of betadine, appropriate dressings, and verification that the wound vac dressing was sealed and functioning at the ordered setting. Review of the resident’s March Treatment Administration Record revealed missing documentation for ordered wound care to the right fifth toe surgical site and right heel wound on several dates, and no documentation that the wound vac dressing was changed or that the wound vac was properly functioning on additional dates. The DON confirmed that the medical record did not contain documentation to support that the ordered wound care and wound vac management were completed on the identified dates. Facility policies on Pressure Injury Risk Assessment and Prevention of Pressure Injuries required comprehensive skin assessments upon admission and ongoing documentation of skin condition, type of assessment, dates and times of care, and related observations, but the records for these residents did not reflect compliance with those requirements.
Failure to Provide Adequate Supervision During Incontinence Care Resulting in Bed Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and safe care to prevent a fall for Resident #84, who had moderate cognitive impairment and was dependent on staff for toilet hygiene, bed mobility, transfers, and bathing. The resident had diagnoses including COPD, anxiety, diabetes mellitus, hypertension, and unspecified hemiplegia, and had a physician’s order for a pressure reduction mattress. On the date of the incident, nursing notes documented that the nurse found the resident on her bedroom floor, lying on her back with her head against the bedside stand, after the resident reported that a CNA had left her alone in bed to obtain more linen. The resident complained of pain in her right leg and right arm, and x‑rays were later documented as negative for fractures. In interviews, the resident stated she had been left on her side on a low air loss mattress during incontinence care when the aide left the room to get more linen, and that the mattress inflated and pushed her out of bed. CNA #130 confirmed she was providing incontinence care, left the resident on her side in bed to get linen, did not lower the bed to its lowest position, and was the only staff member present despite the resident requiring two‑person assistance for incontinence care and bed mobility. The DON confirmed that the resident required two‑person assistance for bed mobility, transfers, and incontinence care, and that the CNA had left the resident alone on her side on a low air loss mattress, which resulted in the fall. The facility’s Falls‑Clinical Protocol policy described evaluation and documentation of falls but did not prevent the circumstances that led to this witnessed fall.
Failure to Routinely Inspect and Maintain Crash Carts
Penalty
Summary
The facility failed to ensure that crash carts were routinely inspected and properly maintained, as required by facility policy. Observations revealed that crash carts in multiple halls were either unlocked, missing essential equipment such as ambu bags, or had Automated External Defibrillator (AED) pads improperly stored. Review of crash cart sign-off sheets showed that checks were inconsistently performed, often by only one nurse, and not on every shift as required. In some cases, there was no documentation indicating that the contents of the crash carts had ever been checked, and when the lock was changed, content checks were not always completed. Interviews with staff confirmed that crash carts were not checked nightly and that required documentation and verification of cart contents were lacking. Review of the crash cart checklist further revealed that several required items were not initialed as present in the cart. Facility policy mandates daily inspection of crash carts by designated nursing personnel, with deficiencies to be reported and corrected immediately, but these procedures were not followed. This deficiency had the potential to affect all residents identified as Full Code, as the facility census included 87 residents, with 47 identified as Full Code.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plan for a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, unsteadiness on feet, and disorientation. The care plan specified the use of non-skid material under and on top of the wheelchair cushion, as well as non-skid strips on the closet side of the bed. However, during observation, these interventions were not in place; there were no non-skid strips on the closet side of the bed and no non-skid material in the resident's Broda chair. This was confirmed by a CNA during an interview. The facility's policy required staff to identify and implement interventions based on the resident's specific risks to prevent falls, but these measures were not followed for this resident.
Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, which had the potential to affect all residents receiving food and beverages. An interview with a family member of Resident #38 revealed that another family member was allowed into the kitchen and observed it to be unsanitary. During an observation, a ceiling tile behind the tray line was found to be water damaged, cracked, and bowing outwardly toward the floor. Dietary Aide #72 confirmed the condition of the ceiling tile and mentioned that it sometimes leaked when it rained. The Dietary Director acknowledged the ceiling leak but stated he had not seen it actively leaking. A review of the facility's policy from September 2017 indicated that the Dining Services Director was responsible for ensuring the kitchen was maintained in a clean and sanitary manner, including the floors, walls, ceiling, lighting, and ventilation.
Failure to Ensure Proper Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to ensure proper hand hygiene during lunch meal service, which had the potential to affect 113 residents who ate food served from the kitchen. Observations revealed that Cook #309 donned clean gloves without completing any hand hygiene and proceeded to touch food items, adjust his clothing, and handle various kitchen items with the same gloves. Cook #310 was also observed handling food and kitchen equipment without changing gloves or performing hand hygiene. Both cooks continued their tasks without adhering to proper hand hygiene protocols, as outlined in the facility's policy on hand washing. The Dietary Manager confirmed the observations and acknowledged that Cook #309 had never worked as a cook in a nursing facility before. The facility's policy required employees to wash their hands before engaging in food preparation, during food preparation as necessary to prevent cross-contamination, and before donning and after removing disposable gloves. The deficiency was investigated under Complaint Number OH00153638.
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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 Marion
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marion Nursing & Rehab | 0.5 mi | ★★★★★ | 21 | 0 |
| Meadows Of Marion Health And Rehabilitation The | 1 mi | — | 2 | 0 |
| Marion Pointe | 1.7 mi | ★★★★★ | 12 | 0 |
| Harding Pointe | 2.1 mi | ★★★★★ | 19 | 0 |
| Presidential Post-acute | 2.7 mi | ★★★★★ | 4 | 0 |
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