Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 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.
Unsafe and Unmaintained Resident Room Conditions: A resident with severe cognitive impairment had damaged window blinds with missing slats and tissue paper taped over the opening, another resident with DM and heart/kidney disease had an A/C vent leaking water onto the wall and bed linens, and a cognitively intact resident had an off-center, rocking toilet with an ill-fitting tank lid that left the tank interior visible. Staff and maintenance interviews showed the issues were not documented in the maintenance log before survey observation.
A resident with severe cognitive impairment and diagnoses including traumatic subdural hemorrhage and cerebral infarction had a PRN lorazepam order for anxiety with no end date listed. The DON stated the order should have had a 14-day stop date and been reevaluated for extension, and the Administrator acknowledged the PRN order should have had an end date.
Failure to Maintain Ordered Oxygen Tubing and Humidifier Care: A resident with COPD and oxygen therapy had tubing and a water reservoir that were not changed as ordered. Observations showed the tubing remained dated from an earlier date and the reservoir was empty, while the resident reported dry nose discomfort. The DON and Administrator stated that nursing staff were responsible for replacing the tubing and water reservoir per order and policy.
An unlocked med cart was found unattended in a hallway with syringes, insulin, and oral meds accessible, and an LPN stated she had left it unlocked after lending out her keys and being called away. In a separate observation, a resident with anemia, constipation, dysphagia, intact cognition, and very poor vision was found with a cup containing an unknown red liquid on the bedside dresser while the resident was not in the room. The DON and Administrator stated meds were to be observed until taken, and facility policy required carts to remain locked when not in use or out of sight.
A resident’s personal refrigerator contained expired [NAME] salami that was greyish and sitting in sour-smelling liquid, and the resident said he did not know it was spoiled and would have eaten it. The resident had vascular dementia, diabetes, and a hx of stroke with cognitive deficits, while staff gave conflicting accounts of who was responsible for checking resident refrigerators and removing expired food.
A resident with a Foley catheter and EBP requirements received catheter care from two CNAs who did not don gowns before the procedure, even though PPE was available outside the room and an EBP sign was posted. The resident’s care plan required gown and glove use for device care, including catheter care, and staff interviews confirmed they knew gowns were required and identified cross contamination and infection spread as the concern.
A resident with COPD, prior CVA, repeated falls, pain, and moderate cognitive impairment did not have a working call light at bedside. The resident stated the call light had not worked since admission, and surveyors confirmed the button on the bed side did not function. Staff had moved another call light from across the room, but the issue was not documented in the maintenance logbook, and the DON, LVN, CNA, and Maintenance Supervisor each described that the problem had not been properly reported before surveyor inquiry.
Pest Control Program Not Effective in B Wing: A resident’s bathroom had roaches and a water bug entering through a hole in the wall, and another resident’s bathroom had several cockroaches going under the toilet and into loose wall trim. Staff reported a pest problem in B Wing for months, the DON said the contracted pest control service needed to come more often and focus on that area, and the Maintenance Mgr said insects were seen occasionally and pest control came once a month.
Failure to Obtain Immediate Physician Orders for Wounds at Admission: A resident admitted with gangrene, DM2, and osteomyelitis had a recent toe amputation with a surgical wound and a stage II sacral PU, but no wound care orders were in place on admission. The admitting LVN stated she forgot to contact the MD, and the treatment nurse later found no wound care orders when she assessed the resident; orders for the incision and sacrum were not entered until several days later, and no wound care was documented in the interim.
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.
Unsafe and Unmaintained Resident Room Conditions
Penalty
Summary
The facility failed to provide a safe, clean, sanitary, comfortable, and homelike environment for 3 of 22 resident rooms. Resident #56, a male with diagnoses including traumatic subdural hemorrhage and cerebral infarction, had severe cognitive impairment and required substantial assistance with toileting, bathing, and lower-body dressing. During observation, his window blinds were noted to have two slats with large missing gaps on the lower left edge, allowing sunlight into the room and into his eyes. On later observations, tissue paper was taped over the missing section of the blinds, and the condition remained unchanged on subsequent observation. Resident #103, a female with diagnoses including type II diabetes and hypertensive heart and chronic kidney disease with heart failure, had moderate cognitive impairment and required substantial assistance with toileting, bathing, and lower-body dressing. She used a wheelchair. During observation and interview, she stated that the air conditioner vent leaked down the wall onto her sheets and left a cold wet spot on the bed. Wet streaks were observed trailing down the wall from the vent, and a wet spot was noted on her sheets. Later observation showed a dinner-plate-sized wet spot on the sheets and water dripping from the vent onto the bed area. Resident #95, a cognitively intact male with diagnoses including cerebral infarction, major depressive disorder, and adjustment disorder, required partial to moderate assistance with toileting hygiene. His toilet was observed to be off center, with the front of the base pushed to the right. The lid on the tank did not fit the tank and was too large, leaving the inside of the tank visible and pushing forward the toilet seat. The resident stated he wanted the toilet fixed, said it rocked back and forth, was scared the lid would fall off and break, and reported that the condition had been present for months. The maintenance log reviewed for the unit did not contain requests for repair of his toilet, and staff interviews reflected that the issue had not been entered into the maintenance book until after the observation.
PRN Lorazepam Order Lacked Required End Date and Reevaluation
Penalty
Summary
The facility failed to ensure the drug regimen for Resident #56 was free from a PRN psychotropic medication order that remained active beyond 14 days without a documented physician evaluation, rationale for extension, or duration for continued use. Resident #56 was a readmitted male with diagnoses including traumatic subdural hemorrhage and cerebral infarction, and his admission MDS indicated he was unable to make himself understood or understand others, with a BIMS score of 00 showing severe cognitive impairment. Record review showed an order for lorazepam 0.5 mg by mouth every 4 hours as needed for anxiety with a start date of 07/02/2026 and no end date listed. During interview, the DON stated the resident was on hospice and used lorazepam frequently, and acknowledged the order should have had a 14-day end date and been reevaluated for extension if needed. The Administrator stated the PRN lorazepam should have had an end date and said he did not know the risk of it not having one.
Failure to Maintain Ordered Oxygen Tubing and Humidifier Care
Penalty
Summary
The facility failed to ensure that a resident who required respiratory care received oxygen equipment maintenance as ordered. Resident #14, a female with diagnoses including Chronic Obstructive Pulmonary Disease, shortness of breath, and nausea, had a quarterly MDS showing a BIMS of 12 and indicated that she received oxygen therapy. Her physician’s order dated 6/19/2026 directed staff to change the oxygen tubing every night shift every Wednesday, and her care plan stated that staff were to change her oxygen tubing as per facility policy. During observations on 7/27/26 and 7/28/26, Resident #14’s oxygen tubing was observed labeled and dated 7/20, and the water reservoir was empty and dated 7/20. During the 7/28/26 observation and interview, Resident #14 stated that her nose was getting dry and that a nurse should come by and change it for her. The DON stated that night nurses were responsible for replacing oxygen tubing and the water reservoir, and the Administrator stated that nursing staff were expected to replace oxygen tubing and water reservoirs as ordered. The facility policy on Oxygen Administration required checking the humidifying jar, ensuring water was present, and documenting the date and time the procedure was performed.
Unlocked Medication Cart and Unobserved Resident Medication
Penalty
Summary
The facility failed to ensure drugs were stored in a locked compartment and accessible only to authorized personnel. During an observation on 7/28/26 at 12:30 PM, the medication cart on Hall C was found unlocked and unattended in the hallway near the nurse’s station. The drawers were accessible, and when opened by the surveyor, syringes, insulin, and oral medications were present. LVN F stated she was responsible for the cart and that it was supposed to be locked, but she had let someone use her keys and left the cart unlocked while she continued working and was later called away. Resident #71 was also observed with a medication cup containing an unknown red liquid sitting on the bedside dresser during an observation on 7/27/26 at 9:28 AM. The resident was not in the room at the time of the observation. Resident #71’s record showed diagnoses including anemia, constipation, and dysphagia, and the annual MDS dated 06/30/26 indicated a BIMS score of 14 with intact cognition. The care plan noted very poor vision and eyesight and directed staff to provide a safe environment. During interviews, the DON stated the medication aide or nurse was expected to watch the resident to ensure medications were taken before leaving the resident unsupervised. The Administrator stated it was the responsibility of the medication aide or nurse to ensure residents actually took their medications. Facility policies reviewed stated medication carts must be secured during medication passes, kept locked when not in use, and kept closed and locked when out of the medication nurse or aide’s sight.
Spoiled, Expired Meat Left in Resident Refrigerator
Penalty
Summary
The facility failed to maintain safe and sanitary storage of a resident’s food items in a personal refrigerator. During observation, a package of [NAME] salami was found in Resident #71’s refrigerator with an expiration date of 05/10/26. The meat was greyish around the edges and there was a large amount of sour-smelling liquid in the container. The same spoiled, out-of-date salami was observed again during a later observation and interview, and Resident #71 said he did not know it was spoiled and would have eaten it. Resident #71’s record showed diagnoses including vascular dementia, diabetes, and cerebral infarction. The MDS indicated he was cognitively intact with a BIMS score of 14 and required setup or clean up assistance with eating, while the care plan also noted impaired cognitive and decision-making abilities due to a history of stroke with cognitive deficits. Staff interviews showed conflicting responsibility for cleaning resident refrigerators, with CNA, housekeeping, RN, DON, and the Administrator all discussing refrigerator cleaning and expired food removal, and the Administrator stated housekeeping had been overseeing the task. The facility policy stated foods must be received and stored in a manner that complies with safe food handling practices and that designated staff will maintain clean food storage areas at all times.
Failure to Use Gowns During Catheter Care Under EBP
Penalty
Summary
The facility failed to maintain an infection prevention and control program when CNA G and CNA H did not don gowns before providing catheter care to Resident #31, who was on enhanced barrier precautions. Resident #31 was a male resident with diagnoses including benign prostatic hyperplasia and infection following a procedure. He had an indwelling Foley catheter, required moderate assistance with ADLs, and was cognitively intact with a BIMS score of 13. Resident #31’s care plan identified the need for enhanced barrier precautions because he had an open wound and a Foley catheter. The care plan directed staff to wear a gown and gloves for high-contact resident care activities, including device care such as catheter care, and to ensure appropriate PPE was available outside the room. The order summary also reflected enhanced barrier precautions while providing personal care every shift for the Foley catheter, and urinary catheter care every shift. During observation, CNA G and CNA H performed catheter care without putting on gowns, despite the EBP sign on the room door and PPE being available outside the room. In interviews, CNA H and CNA G stated they should have worn gowns and identified cross contamination as the risk. LVN L, ADON K, the DON, and the Administrator each stated staff were expected to wear the appropriate PPE during catheter care and that the risk was cross contamination, infection control, or the spread of infection.
Nonfunctioning Bedside Call Light
Penalty
Summary
The facility failed to ensure a working call system was available at a resident’s bedside. Resident #42 was a male with diagnoses including acute and chronic respiratory conditions, COPD, pain, chest pain, repeated falls, cerebral infarction, shortness of breath, and hemiplegia and hemiparesis following a cerebral infarction. His MDS assessment reflected moderate cognitive impairment with a BIMS score of 12, and he was dependent on all ADLs. He was also occasionally incontinent of bowel and bladder, and his care plan included interventions to encourage use of the call light and keep it within reach. During observation and interview, the resident stated his call light did not work beside his bed and had not worked since he had been in the room. The surveyor tested the call light button on the resident’s side of the bed and it did not work. The resident stated staff knew the call light did not work, and staff had moved the other call light from the opposite side of the room to his side of the bed. Later observations again showed the call light at bedside was not working, and the resident stated the facility still had not fixed it. Record review of the maintenance request book did not show an entry for the room’s call light problem. A CNA stated the call light next to the bed was not working and that she was not sure if anyone had looked at it or if it had been reported. An LVN stated she was not aware of the problem and would put it in the maintenance logbook. The Maintenance Supervisor stated he was not aware of the issue until staff contacted him that day and that it had not been in the maintenance logbook before then. The facility policy stated defective call lights should be reported promptly.
Pest Control Program Not Effective in B Wing
Penalty
Summary
The facility failed to maintain an effective pest control program for B Wing. During observation and interview, Resident #6’s bathroom had a large roach about half an inch in size, several small roaches on the floor, and a large water bug about 2 inches long entering a hole in the wall. Resident #6 stated that the bugs bothered him, that they came into his room as well, and that he did not know whether anything had been done about them, although they had been there for a while. At another observation, Resident #29’s bathroom had several large cockroaches going under the toilet and into loose wall trim. An anonymous staff member stated there was a pest problem in B Wing and that pest control had not been seen in that part of the building for a while, with roaches and other bugs present in that section for 6 months. The DON stated the contracted pest control service needed to come more often and focus on that part of the building, while the Administrator stated maintenance was responsible for preventing pests from entering through wall damage and that pest control should direct attention to problem areas. The Maintenance Manager stated he saw insects occasionally in B Wing, that pest control came once a month, and that he could caulk or fix the floor trim to seal the bathroom entry points.
Failure to Obtain Immediate Physician Orders for Wounds at Admission
Penalty
Summary
The facility failed to obtain physician orders for the immediate care of Resident #1’s surgical wound and stage II pressure ulcer at admission. Resident #1 was admitted with diagnoses including gangrene of a wound, type II diabetes, and osteomyelitis, and had recently undergone amputation of all toes on the right foot. Record review showed he had a surgical wound from the amputation and a stage II pressure ulcer to the left sacrum noted on the admission assessment, but there were no wound care orders for either wound from the time of admission until 04/06/2026. The MD orders entered on 04/06/2026 included treatment for the right transmetatarsal incision and sacrum, and the MAR/TAR showed no wound care was provided from 04/03/2026 through 04/06/2026. During interview, the admitting LVN stated the resident arrived late on a Friday, department heads were gone, and she forgot to contact the MD regarding the wounds. The treatment nurse stated it was the admitting nurse’s responsibility to complete the initial wound evaluation and call the MD for orders, and that the resident had no wound care orders when she evaluated him on 04/06/2026. The DON and Administrator stated the admitting nurse was responsible for entering orders, completing the admission assessment, notifying the physician, and ensuring needed orders were in the EHR.
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.
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 104 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.
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 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 | ★★★★★ | 24 | 1 |
| Treviso Transitional Care | 20.4 mi | ★★★★★ | 2 | 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 October 2026) and official state health department websites.