Above average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Marshall Manor Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Two residents with limited range of motion did not receive appropriate restorative therapy and splint application as recommended by occupational therapy and documented in care plans. One resident did not receive restorative exercises for two weeks after therapy discharge due to unclear referral processes, while another was not consistently provided with a prescribed hand splint because of staff confusion over responsibility and documentation.
Surveyors identified multiple infection control deficiencies, including improper hand hygiene and glove use by a CNA during incontinent and catheter care for a resident with complex medical needs, failure to implement contact isolation for a resident with VRE, and improper storage of laundry items on the floor. These lapses were confirmed through staff interviews and direct observation.
A resident with multiple medical conditions, including impaired mobility and risk for skin breakdown, reported discomfort with his mattress and requested a replacement. Despite multiple complaints, there was confusion among staff about whether a maintenance request had been submitted, leading to a delay in replacing the mattress. The facility lacked a process for scheduled mattress inspections, and the issue was only addressed after a formal request was finally made.
A resident with a stage 2 sacral pressure ulcer and multiple risk factors was found to have a pressure-relieving mattress set at a weight far above her actual weight for several days. Staff interviews revealed confusion about who was responsible for setting the mattress correctly, and facility policies required settings to be based on individual weight. This failure resulted in the resident not receiving care consistent with professional standards for pressure ulcer prevention and treatment.
A resident with an indwelling urinary catheter did not receive proper catheter care or securement as ordered, with staff failing to use a securement device and not following correct hand hygiene or care sequence during incontinence and catheter care. Staff interviews confirmed that these actions did not meet facility policy or training requirements.
The facility did not ensure that the attending physician or nurse practitioner documented a rationale in the medical record when disagreeing with the consultant pharmacist's recommendations for two residents during medication regimen reviews. In both cases, recommendations to discontinue or adjust medications were not followed, and no justification was provided, despite facility policy requiring such documentation.
A CNA Class Instructor entered the kitchen during meal service without a hairnet while food was being plated, in violation of facility policy requiring all staff to wear hair restraints in the kitchen. This was confirmed by staff interviews and review of the facility's food preparation and service policy.
A resident with a history of recurrent UTIs and moderate cognitive impairment was prescribed a prophylactic antibiotic, which was not discontinued when a second antibiotic was started for an active infection. Facility staff failed to communicate and monitor concurrent antibiotic use, resulting in the resident receiving two cephalosporins at the same time, contrary to the facility's antibiotic stewardship policy.
A resident with severe cognitive impairment and legal blindness was physically abused by another resident with a history of behavioral issues, including poor impulse control and previous altercations. The incident occurred in a hallway and was witnessed by a CNA. Despite existing care plans and staff awareness of the aggressor's behavioral risks, the facility did not prevent the altercation, resulting in a deficiency for failure to protect residents from abuse.
The facility failed to develop and implement comprehensive care plans for three residents, including the use of transfer bars and a seizure safety helmet, leading to potential risks and unmet needs.
The facility failed to enforce its smoking and fire safety policies, resulting in a resident's smoking materials being left in their room and multiple residents having items placed on overhead light fixtures, creating potential fire hazards.
The facility failed to ensure that a resident with a diagnosis of bipolar disorder received an accurate PASRR Level 1 assessment. The assessment, completed by an RN case manager at a local hospital, did not reflect the resident's bipolar disorder diagnosis, which was not caught by the MDS Coordinator or during care plan meetings. This oversight could have impacted the specialized services the resident received.
The facility failed to ensure a resident's drug regimen was free from unnecessary psychotropic drugs due to inadequate behavior and side effect monitoring. The resident was administered Haloperidol without documented behaviors to justify its use or effectiveness, and staff interviews revealed a lack of proper documentation and monitoring.
A CNA failed to perform hand hygiene between assisting two residents with their meals, leading to a risk of cross-contamination and infection. Both residents required full assistance with eating, and the CNA's actions were not in compliance with the facility's infection control policies.
Failure to Provide Restorative Therapy and Splint Application for Residents with Limited ROM
Penalty
Summary
The facility failed to provide appropriate restorative therapy and services to two residents with limited range of motion (ROM), as recommended by occupational therapy and documented in care plans. One resident, a male with a history of diabetes, pituitary gland neoplasm, and bilateral hip replacements, was discharged from occupational therapy with a recommendation for restorative nursing exercises. Despite this, there was no documentation of restorative services being provided for two weeks following the therapy discharge. Interviews revealed confusion among staff regarding the referral process and responsibility for initiating restorative services, resulting in the resident not receiving the recommended exercises during this period. Another resident, a female with a history of cerebral infarction, hemiplegia, hemiparesis, and rheumatoid arthritis, was identified as needing a left upper extremity splint to prevent further contracture. Despite this, observations over several days showed that the resident was not wearing the splint, and staff interviews indicated a lack of clarity regarding who was responsible for applying the splint. The restorative plan of care did not reflect the need for the splint, and staff were unaware of the specific requirements for its use, leading to inconsistent application and documentation. Both cases demonstrate failures in communication and implementation of restorative care plans, resulting in residents not receiving necessary interventions to maintain or improve their range of motion. The lack of coordination between therapy, nursing, and restorative staff contributed to these deficiencies, as evidenced by missing documentation, unclear responsibilities, and inconsistent follow-through on recommended treatments and device use.
Infection Control Failures in Resident Care and Laundry Handling
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices in several areas, as observed and documented by surveyors. In one instance, a certified nursing assistant (CNA) did not follow correct hand hygiene and glove-changing protocols while providing incontinent and catheter care to a 94-year-old male resident with multiple diagnoses, including heart failure, sepsis, and acute kidney failure. The CNA performed care on the resident's buttocks and then applied a clean brief without changing gloves or sanitizing hands, and subsequently touched the resident's pants with contaminated gloves. Interviews with other staff confirmed that the CNA did not follow the expected sequence of care or proper hygiene practices, which could lead to contamination and infection. Another deficiency was identified when a female resident with a urinary tract infection caused by vancomycin-resistant enterococcus (VRE) was not placed on contact isolation after laboratory results confirmed the presence of this resistant organism. The Director of Nursing (DON), who also served as the Infection Control Practitioner (ICP), was unaware of the VRE result and did not initiate appropriate isolation precautions. Staff interviews revealed that the standard practice was to place residents with VRE on contact isolation to prevent the spread of infection, but this was not done until much later, after the oversight was discovered. Additionally, the facility's laundry room was found to have multiple instances of clean and soiled laundry items, including resident clothing and lift pads, stored directly on or touching the floor. The housekeeping supervisor acknowledged that this practice was not in line with infection control standards and could result in cross-contamination. Observations showed that items were placed back into circulation after touching the floor, and staff responsible for laundry oversight did not consistently ensure proper storage and handling of laundry to prevent contamination.
Failure to Timely Accommodate Resident Mattress Request
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident had a comfortable mattress, as required to reasonably accommodate the needs and preferences of each resident. The resident, a male with a history of cerebral infarction, pain, insomnia, type 2 diabetes, hemiplegia, and hemiparesis, was at risk for developing pressure ulcers and required setup assistance for activities of daily living. The resident reported that he had requested a new mattress at the beginning of the previous week due to discomfort and the mattress being thin, but had not received one at the time of the initial observation. Staff interviews revealed that the resident had complained multiple times about the mattress, and it was noted that the mattress may have developed a hole due to previous weight changes. However, there was confusion among staff regarding whether a maintenance request had been submitted, with some staff stating they may have verbally informed maintenance or believed someone else had submitted the request. The maintenance staff confirmed that the first formal request was received and addressed on a specific date, and the mattress was found to have an indentation. The facility did not have a process for scheduled mattress inspections, and maintenance issues were generally reported by staff, residents, or family members either verbally or through a maintenance request book. The Director of Nursing and other staff acknowledged the importance of a comfortable mattress for resident well-being, but there was no evidence of proactive monitoring or timely response to the resident's initial complaint, resulting in a delay in addressing the resident's discomfort.
Failure to Ensure Proper Pressure-Relieving Mattress Settings for Resident with Pressure Ulcer
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident with a stage 2 sacral pressure ulcer received care consistent with professional standards of practice, specifically regarding the use of a pressure-relieving mattress. The resident, a 97-year-old female with multiple diagnoses including severe cognitive impairment, hemiplegia, contractures, and muscle wasting, was identified as being at risk for pressure ulcers and had an active stage 2 sacral ulcer. Her care plan included the use of a pressure-relieving mattress, regular repositioning, wound care, and nutritional support. Despite these interventions being documented, observations over several days revealed that the resident's pressure-relieving mattress was consistently set at a weight setting of 360 pounds, while her actual weight ranged from approximately 134 to 141 pounds. Multiple staff interviews indicated a lack of clarity regarding responsibility for ensuring the mattress was set correctly according to the resident's weight. Nursing staff, the treatment nurse, the ADON, the DON, and the administrator all acknowledged that the mattress should be set based on the resident's weight and that incorrect settings could negatively impact skin integrity and wound healing. Facility policies reviewed indicated that support surfaces should be selected and set based on individual resident factors, including weight, to prevent skin breakdown. However, the failure to ensure the mattress was set appropriately for the resident's weight represented a lapse in following these policies and professional standards, potentially compromising the effectiveness of the pressure-relieving intervention for this resident.
Failure to Provide Proper Catheter Care and Securement
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter did not receive appropriate catheter care and securement as ordered and per facility policy. The resident, a 94-year-old male with diagnoses including heart failure, sepsis, and acute kidney failure, had physician orders and care plan interventions specifying the use of a catheter leg strap and regular catheter care. During observation, the catheter was found unsecured, and the securement device was not in place as required. Certified Nursing Assistant (CNA) O performed incontinent and catheter care for the resident but did not follow proper procedures. CNA O began care at the resident's buttocks, wiped both buttocks, and applied a clean brief without changing gloves or sanitizing hands. She then changed gloves but did not wash or sanitize her hands before starting catheter care. After performing catheter care, she did not change the dirty brief or gloves before pulling up the resident's pants. These actions were observed and confirmed by another CNA and facility nursing leadership, who noted that the care sequence and hand hygiene were not in accordance with expected standards. Interviews with staff, including the CNAs, LVN, DON, and ADM, confirmed that the resident's catheter was not secured and that proper hand hygiene and care sequence were not followed. Staff acknowledged that the observed practices deviated from facility policy and training, which require front-to-back cleaning, proper glove changes, hand hygiene, and the use of a securement device for all residents with catheters. The facility's policies on urinary continence and catheter care emphasize the importance of these procedures to prevent infection and ensure resident safety.
Failure to Document Rationale for Not Following Pharmacist Medication Recommendations
Penalty
Summary
The facility failed to act upon the recommendations made by the consultant pharmacist during the monthly medication regimen review (MRR) for two residents. In both cases, the attending physician or nurse practitioner did not provide a documented rationale in the medical record for disagreeing with the pharmacist's recommendations, as required by facility policy. This lack of documentation was observed in the records and confirmed through staff interviews. For one resident, who had diagnoses including vascular dementia, Parkinsonism, anxiety disorder, and delusional disorder, the pharmacist recommended discontinuing Seroquel (an antipsychotic medication) unless a clear therapeutic benefit was documented. The physician disagreed with the recommendation but did not provide any rationale or justification in the resident's chart. Interviews with the ADON, DON, and Administrator confirmed that the expectation was for a rationale to be documented, and this was not done. In the second case, another resident with multiple diagnoses including vascular dementia, Parkinson's disease, generalized anxiety disorder, and a history of falls, was identified by the pharmacist as being at increased risk for falls and confusion due to several medications listed on the Beers Criteria. The pharmacist recommended discontinuing certain medications and implementing gradual dose reductions for others. The nurse practitioner responded to the recommendations by noting that a sitter had been provided for the resident, but did not address the specific medication recommendations or provide a detailed rationale for not following them. The DON and Administrator both acknowledged that the response was inadequate and did not meet facility expectations for documentation.
Failure to Enforce Hair Restraint Policy in Kitchen
Penalty
Summary
A deficiency occurred when the CNA Class Instructor entered the facility's kitchen during lunch service without wearing a hairnet, as observed by surveyors. At the time, kitchen staff were actively plating food on the steam table. The instructor entered the kitchen to hand a sticky note to a dietary staff member on the serving line and then exited. When questioned, the instructor acknowledged not wearing a hairnet, stating she was only delivering a note. Interviews with the Dietary Manager and the Administrator confirmed that all staff entering the kitchen are expected to wear hairnets to prevent hair from contaminating food, in accordance with facility policy. The facility's written policy also specifies that only dietary staff are allowed in the kitchen, and that any other staff entering must wear hair restraints. This lapse in protocol was directly observed and confirmed through staff interviews and policy review.
Failure to Discontinue Prophylactic Antibiotic During Active Infection Treatment
Penalty
Summary
The facility failed to promote antibiotic stewardship by not ensuring appropriate use of antibiotic therapy and not providing written rationale from the provider when an antibiotic was used outside of established criteria. Specifically, a resident with a history of recurrent urinary tract infections and moderate cognitive impairment was prescribed Cephalexin as a prophylactic antibiotic, despite the facility's policy discouraging prophylactic antibiotic use. The resident had an indwelling catheter removed in March and had frequent bowel incontinence, with a care plan in place to assess and prevent recurrent UTIs. When the resident developed symptoms and a urine culture indicated the presence of pseudomonas aeruginosa, a new antibiotic, Cefdinir, was ordered to treat the active infection. However, the original prophylactic Cephalexin order was not discontinued, resulting in the resident receiving two cephalosporin antibiotics simultaneously. Nursing staff recognized the issue after the fact but did not immediately notify the provider or discontinue the prophylactic antibiotic. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's concurrent antibiotic orders. The DON, who oversaw the antibiotic stewardship program, was unaware of the prophylactic Cephalexin order and confirmed it should have been discontinued when the new antibiotic was started. The nurse practitioner who prescribed the antibiotics also stated she was not reminded of the ongoing prophylactic order and emphasized the risks of unnecessary dual antibiotic therapy. The facility's policy required antibiotics to be prescribed only for active infections or suspected sepsis, based on clinical criteria and culture results.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from physical abuse by another resident. The incident involved a female resident with severe cognitive impairment, legal blindness, and altered mental status, who was rarely or never understood and had a BIMS score of 00. This resident was sitting in her wheelchair in the hallway when another resident, who had a moderate intellectual disability, generalized anxiety disorder, and a history of behavioral issues, approached and kicked her on the left leg below the knee. The event was witnessed by a CNA, and the resident who was kicked was assessed immediately after the incident, with no apparent injury or pain noted at that time. The resident who committed the act had a documented history of poor impulse control, episodes of agitation, and previous incidents of hitting other residents. Staff interviews confirmed that this resident was known to be bossy, argumentative, and had difficulty regulating emotions and behaviors. The care plan for this resident included interventions for behavioral symptoms, such as calmly redirecting inappropriate behavior and providing supervision. Despite these interventions, the resident was able to approach and physically abuse another resident in a common area. Prior to the incident, staff were aware of the behavioral risks associated with the resident who committed the abuse, including a previous similar incident earlier in the year. The facility's failure to prevent this altercation, despite knowledge of the resident's behavioral history and the vulnerability of the other resident, led to the deficiency. The incident was observed, documented, and reported by staff, and the residents involved were assessed following the event.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for three residents, leading to deficiencies in meeting their medical, nursing, mental, and psychosocial needs. Resident #13 and Resident #47 did not have care plans for the use of transfer bars, which were observed to be in use during the survey. Despite the presence of these bars, there were no documented interventions or care plans addressing their use, which could lead to confusion among staff about their purpose and proper use. This lack of documentation was confirmed through interviews with staff, who acknowledged the absence of care plans for the transfer bars and the potential risks associated with their use without proper guidance. Resident #73's care plan included an intervention to wear a seizure safety helmet while out of bed, but this intervention was not implemented. Observations on multiple occasions revealed that Resident #73 was out of bed and in her wheelchair without the seizure helmet, despite the care plan's directive. Interviews with staff, including CNAs and LVNs, confirmed that the helmet was necessary for seizure precautions and that its absence could lead to serious injury during a seizure. Staff admitted to noticing the resident without the helmet and acknowledged their responsibility to ensure it was worn, yet failed to do so. The facility's failure to develop and implement appropriate care plans for the use of transfer bars and the seizure safety helmet placed residents at risk of not having their individual needs met and not receiving necessary services. Interviews with the ADON, DON, and other staff highlighted the importance of care plans in guiding care and ensuring resident safety. The lack of care plans for the transfer bars and the failure to implement the seizure helmet intervention were identified as significant deficiencies that could lead to adverse outcomes for the residents involved.
Failure to Enforce Smoking and Fire Safety Policies
Penalty
Summary
The facility failed to ensure Resident #32's smoking materials were locked up at the nurse's station as required by the facility's smoking policy. During an observation, Resident #32's cigarettes and lighter were found on his bedside table while he was not in the room. Interviews with the CNA, DON, and Administrator confirmed that the facility policy mandates smoking materials be kept at the nurse's station to prevent fire hazards, and staff are responsible for enforcing this policy. However, the policy was not followed, placing the resident and others at risk of fire hazards. The facility also failed to ensure that objects were not placed on top of overhead light fixtures in the rooms of Resident #19, Resident #47, Resident #62, and Resident #73. Observations revealed that stuffed animals, picture frames, and privacy curtains were placed on the overhead light fixtures, which were turned on. Interviews with various staff members, including CNAs, LVNs, the ADON, and the DON, indicated that placing items on overhead lights is a safety hazard and a fire risk. Despite this, the items were not removed, and the policy was not enforced. The facility's policies on smoking and fire safety were reviewed and confirmed that smoking materials should be kept in a designated area accessible to staff and that all personnel are responsible for fire prevention. However, the facility failed to adhere to these policies, resulting in potential safety hazards for the residents. Staff interviews highlighted a lack of consistent enforcement of these policies, contributing to the deficiencies observed during the survey.
Failure to Ensure Accurate PASRR Screening for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to ensure that Resident #73, who had a diagnosis of bipolar disorder, received an accurate Preadmission Screening and Resident Review (PASRR) Level 1 assessment. The PASRR Level 1 assessment, completed by an RN case manager at a local hospital, did not reflect the resident's bipolar disorder diagnosis. This oversight was not caught by the MDS Coordinator, who submitted the PASRR Level 1 to the portal, nor was it identified during care plan meetings and IDT meetings with the Local Authority. As a result, the resident was not considered by the state Level II PASRR process to have a serious mental illness, which could have impacted the specialized services they received. The MDS Coordinator and the DON both acknowledged the importance of accurately completing the PASRR Level 1 to ensure residents receive necessary specialized services. Resident #73, a female with multiple diagnoses including bipolar disorder, autism, epilepsy, intellectual disability, and ADHD, was admitted to the facility. The resident's care plan indicated the potential for depression due to nursing home placement and included interventions for additional counseling and referrals to social/psych/activity services as needed. Despite these measures, the PASRR Level 1 assessment failed to mention the bipolar disorder diagnosis, leading to a lack of appropriate specialized services. The facility's undated PASRR policy did not address the accuracy of the PASRR Level 1 assessments, contributing to the oversight.
Failure to Monitor Psychotropic Drug Use
Penalty
Summary
The facility failed to ensure that Resident #25's drug regimen was free from unnecessary psychotropic drugs, specifically Haloperidol, due to inadequate behavior and side effect monitoring. Resident #25, a female with severe cognitive impairment and diagnoses including senile degeneration of the brain, depression, and anxiety disorder, was administered Haloperidol without documented behaviors to justify its use or effectiveness. The medication administration record (MAR) and nurse's notes did not reveal any monitoring for signs and symptoms of anxiety or agitation, nor did they document any non-pharmacological interventions attempted before administering the medication. Interviews with staff, including RN E, LVN G, ADON D, and the DON, revealed that there was a lack of proper documentation and monitoring for Resident #25. RN E admitted to not documenting the reason for administering the PRN Haloperidol or any interventions tried before its administration. LVN G and ADON D confirmed that behavior and side effect monitoring should have been documented every shift, and that non-pharmacological interventions should be attempted before administering PRN medications. The DON emphasized the importance of monitoring to track drug effectiveness and adverse reactions. The facility's Antipsychotic Medication Use policy indicated that staff should gather and document information to clarify a resident's behavior, mood, and function, and monitor for side effects and adverse consequences. However, this policy was not followed in the case of Resident #25, leading to a failure in ensuring the resident's drug regimen was free from unnecessary psychotropic drugs. This deficiency could place residents at risk of possible medication side effects, adverse consequences, and decreased quality of life.
Inadequate Hand Hygiene During Meal Assistance
Penalty
Summary
The facility failed to ensure an infection prevention and control program was properly implemented, as evidenced by the actions of a CNA who did not perform hand hygiene between assisting two residents with their meals. The CNA was observed feeding one resident, then moving to another resident without washing hands or using hand gel, and then returning to the first resident again without proper hand hygiene. This practice was observed during lunch service in the television room, where the CNA alternated between feeding two residents without following hand hygiene protocols. Resident #3, a female with severe cognitive impairment, cerebral palsy, muscle weakness, and protein-calorie malnutrition, required full assistance with eating due to her condition. Resident #70, a female with dysphagia, contractures, muscle weakness, and intact cognition, also required assistance with eating. Both residents were dependent on staff for their meals, and the CNA's failure to perform hand hygiene between feeding them posed a risk of cross-contamination and infection. Interviews with the CNA, LVN, DON, and ADM confirmed that the CNA's actions were not in compliance with the facility's infection control policies. The CNA admitted to not remembering if she had washed her hands between feeding the residents, while the LVN, DON, and ADM all stated that proper hand hygiene was required to prevent cross-contamination. The facility's hand hygiene policy, which was reviewed, indicated that handwashing or the use of hand gel was mandatory before and after assisting residents with meals.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Marshall
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marshall Manor West | 0.1 mi | ★★★★★ | 18 | 1 |
| Heritage House Of Marshall Health & Rehabilitation | 4.1 mi | ★★★★★ | 3 | 0 |
| Avir At Jefferson | 16.4 mi | ★★★★★ | 16 | 0 |
| Whispering Pines Lodge | 19.8 mi | ★★★★★ | 34 | 7 |
| Treviso Transitional Care | 20.4 mi | ★★★★★ | 19 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.