Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 West during CMS and state inspections, most recent first.
A resident with an indwelling catheter, impaired cognition, urinary retention, and a history of UTIs reported lower abdominal and penile pain, and nursing noted cloudy, dark, and thick urine in the catheter tubing. A UA/culture specimen was collected and sent out, but staff did not follow up on the results for several days despite ongoing abnormal urine findings and continued complaints of abdominal pain. Interviews confirmed the LVN, DON, and IP had not tracked the lab results, and a later urine result showed blood, protein, leukocyte esterase, and a positive bacteria screen.
Kitchen sanitation and dishwashing temperature deficiencies: Surveyors observed a fryer with crusted debris, baking sheets and skillets with brown and black buildup, cigarettes and a fly swatter stored in the prep area, and debris on the kitchen floor. Dietary staff were observed with loose hair outside hair restraints, and the Maintenance Supervisor entered the kitchen without a beard restraint. The dishwasher temperature was observed below the manufacturer’s minimum of 120 degrees, while the DM confirmed the required sanitizing temperature and the facility policy requirements.
Kitchen Pest Control Program Not Effective: Surveyors observed roaches in the kitchen during meal prep and again near the food pureeing area. The DM removed one roach, and the DM and Administrator stated the facility had routine pest control every 2 weeks and as needed, with a prior roach issue that had improved. Records showed the last pest control visit treated the kitchen for general pests and noted no issues at that time, while facility policy required kitchen and dining areas to be kept free from roaches and other insects.
Care plan not updated for a resident’s diet preferences. The resident had intact cognition, multiple diagnoses including MI, depression, and HF, and documented food allergies and detailed likes/dislikes. The Dietitian noted the resident was vegetarian and had a detailed list of food intolerances, but the care plan did not list a diet or vegetarian preference. Records also showed a family complaint that the resident’s dietary restrictions and wishes were not being honored, and the order summary reflected conflicting diet information.
Failure to Honor a Resident’s Dietary Preferences: A cognitively intact resident with cardiac-related diagnoses and a documented vegetarian preference was repeatedly served meals that did not match her stated likes, dislikes, and food restrictions. Records showed the dietician documented her as vegetarian, but the care plan, physician orders, and tray card did not reflect that preference. During observation, she was served items such as plain lettuce with corn chips, raw broccoli with ice cream, and brussels sprouts only, and she reported that staff repeatedly ignored what she could and could not eat. The DON and Administrator acknowledged the meals did not meet expectations, while the Dietician stated she had educated the DM on how to accommodate the resident’s diet preference.
Food Handler Certificates Not Current for Dietary Staff: The facility failed to ensure 5 of 9 dietary staff had current food handler certificates. Cook-A and Dietary Aides B, C, D, and E did not have current certificates until surveyor intervention, despite hire dates spanning multiple months and years. The DM stated she could not produce earlier licenses and relied on the staff's online access, while also stating she was responsible for keeping food handlers current.
Stove Burners Failed to Ignite: During an observation, the rear 2nd, 3rd, and 5th burners on a stove would not ignite when turned on until the 3rd try. The pilot light stayed on and the front burners worked, but the DM and Administrator were unaware of the issue at the time and reported no prior problems with the stove. Facility policy required food service equipment to be maintained in good repair.
A resident with dementia, dysphagia, dysphasia, osteoarthritis, and muscle weakness had DNR status documented in the chart, but her OOH-DNR form was incomplete. The DOB section was blank, the qualified relative signature was not properly witnessed, and the required witness signatures at the bottom of the form were missing, which the SS E and DON acknowledged made the document incomplete and not legally binding.
Discharge Planning Not Included in Care Plan: A resident with dementia, CVA-related memory deficits, COPD, and prostate cancer had active plans to return home with family support, but the comprehensive care plan did not include discharge goals, preferences, or interventions. Records and staff interviews showed discharge planning discussions occurred, home health paperwork was pending, and the DON noted the resident was being kept longer due to elopement concerns, yet the care plan still lacked person-centered discharge planning.
A resident with UTI and mycoplasma pneumonia had a PICC line order for IV cefepime, but the care plan did not include PICC dressing care, flushing, or IV antibiotic interventions. The MAR/TAR also lacked documentation for PICC care or IV antibiotic administration, and the MDS nurse confirmed there were no related care plans while the DON stated the PICC line should have had interventions for flushing, dressing changes, and infection monitoring.
Missing PICC Flush Orders for IV Antibiotic Administration: A resident receiving IV cefepime for pneumonia had no orders for PICC line flushing before and after medication administration, and the care plan also lacked PICC dressing care, flushing, and IV antibiotic details. The MAR/TAR had no documentation for PICC flushes or IV antibiotic administration, and both the LVN and DON confirmed the chart lacked the needed orders.
A resident with allergic rhinitis and moderate cognitive impairment had opened OTC Nyquil and Chloraseptic spray left at the bedside without a provider order, care plan, or self-administration assessment. The resident said family brought the meds in for cough and tooth pain, and the DON confirmed the facility knew the meds were at the bedside but there was no order or assessment on file. Facility policy required drugs and biologicals to be stored in locked compartments.
A resident with dementia and mobility impairments, requiring mechanical lift and two-person assistance for transfers, was manually transferred by a CNA without the required equipment or assistance. This improper transfer led to extensive chest bruising and multiple rib fractures, as confirmed by medical evaluation. Interviews and records indicated that the CNA did not follow the care plan, and the resident and family had previously reported pain during transfers.
A resident with a history of falls and significant neurological conditions experienced a fall resulting in a hip fracture. Despite a care plan conference where interventions such as a therapy evaluation, dropping the wheelchair seat, and adding non-skid material were agreed upon, these actions were not implemented due to funding issues and oversight. Staff interviews confirmed that the care plan interventions were not carried out as documented, contrary to facility policy.
The facility failed to notify residents of meal substitutions on two consecutive days, serving different meals than those planned without informing the residents. The Dietary Manager confirmed that substitutions were made due to supply issues but were not communicated. Several residents expressed dissatisfaction with the meals, and the facility's policy did not address notification of meal substitutions.
The facility was found to have deficiencies in kitchen sanitation, including improper thawing of chicken, unlabeled and undated food items, and a lack of cleanliness on the kitchen stove. Interviews with staff confirmed these practices were not in line with facility policies, posing a risk for foodborne illnesses.
A resident with severe cognitive impairments was observed without a catheter privacy bag in communal areas, compromising her dignity. Staff interviews confirmed the expectation for privacy covers, and facility policies supported this practice. Despite available resources, the facility failed to ensure the resident's dignity was maintained.
The facility failed to include sensory deficits in the care plans of two residents, one with vision impairment and another with hearing difficulties. Despite observations and staff interviews confirming these needs, the care plans did not address them, potentially impacting the residents' quality of life and safety.
A resident with severe cognitive impairment and existing pressure ulcers did not receive documented wound care on two evening shifts, as required by their care plan. Despite the facility's policy and staff awareness of the importance of following treatment orders, the MAR/TAR lacked documentation for these treatments, potentially affecting the resident's wound healing process.
A resident with a history of dementia and urinary issues did not receive timely changes of their catheter bag and supra-pubic catheter as ordered, placing them at risk for infections. The facility's records showed discrepancies in the scheduled changes, and interviews with staff revealed issues such as locked supplies and lack of documentation. The DON emphasized the importance of following physician orders to prevent infections, but the facility's policy did not address the frequency of changes.
A resident's personal refrigerator contained expired food items, including milk, due to the facility's failure to adhere to its policy of daily checks and weekly cleaning. Despite a care plan addressing the resident's tendency to hoard, staff inconsistencies and lack of documentation led to the deficiency, posing a risk for foodborne illness.
A facility failed to maintain an effective infection control program for a resident with a pressure ulcer. The resident lacked necessary signage and PPE for Enhanced Barrier Precautions (EBP), and a wound care nurse did not wear a gown during care. The DON admitted to oversight in placing the resident on EBP after contact isolation for C. difficile. Facility policy requires gowns and gloves during high-contact care to prevent MDRO spread.
Two residents in a LTC facility experienced abuse by staff members. A CNA verbally and physically abused a male resident with dementia, while a DA verbally abused a female resident with mental health disorders. Both incidents were witnessed and reported, leading to staff suspensions and terminations. The facility's failure to prevent these abuses was noted by surveyors.
The facility failed to implement its abuse prevention policies, resulting in two incidents where staff did not immediately report abuse. In one case, a CNA delayed reporting another CNA's physical and verbal abuse of a resident due to fear. In another, a dietary aide verbally abused a resident, and a new CNA did not report it immediately, misunderstanding the situation. Both incidents highlight deficiencies in staff training and adherence to reporting protocols.
The facility failed to report abuse incidents involving two residents and two staff members within the required timeframe. In one case, a CNA delayed reporting physical and verbal abuse due to fear, while in another, a dietary aide verbally abused a resident, and the incident was not reported immediately by a witness. Both incidents highlight a breakdown in the facility's abuse reporting system.
Failure to Follow Up on Urine Specimen Results
Penalty
Summary
The facility failed to provide appropriate care and services to prevent urinary tract infections to the extent possible for a resident with an indwelling catheter. The resident had multiple sclerosis, urinary retention, neuromuscular dysfunction of the bladder, benign prostatic hyperplasia, a history of UTIs, moderately impaired cognition, and an indwelling catheter. His care plan identified him as being at risk for frequent UTIs, dislodgement, and other catheter-related complications, and directed staff to monitor and report changes such as foul-smelling or turbid urine, blood in the tubing or drainage bag, cloudy urine, pain, and signs of infection around the catheter. On 01/29/26, the resident reported pain radiating from the lower abdomen/stomach down to his penis. On 01/30/26, nursing documented that his lower abdomen was slightly distended, he complained of pain when touched, and his catheter tubing had cloudy urine sediment. Hospice was contacted and an order was received for a urinalysis with culture and sensitivity for complaint of lower abdominal pain. The urine specimen was collected that morning and placed in the refrigerator for pickup, and the resident continued to have abnormal urine findings in the catheter tubing over the next several days, including amber urine, dark urine, cloudy urine, thick mucous-tinged urine, thick yellow urine, and thick yellow/white mucous appearing urine. The record showed no documentation that laboratory results were received during this period, and staff interviews confirmed they had not followed up on the specimen or results. The LVN stated she had not followed up with the hospice nurse on the results, and the DON stated the specimen had been sent to hospice’s lab but the facility had not followed up on the report. The IP also stated she was not aware the results had not returned and had not followed up with the CN, hospice nurse, or laboratory. A later urine result showed dark yellow urine with 3+ blood, 2+ protein, 3+ leukocyte esterase, and a positive bacteria screen, but the final laboratory results had not been received before the survey team exited the facility.
Kitchen sanitation and dishwashing temperature deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards during a kitchen sanitation observation. Surveyors observed the fryer with thick layers of brown and yellow crusted debris on the outside and black and brown debris above the frying baskets. Thirteen baking sheets and four skillets also had brown and black buildup and debris particles on their surfaces. In addition, a pack of cigarettes and a fly swatter were stored on the kitchen prep table under four cutting boards and touching two oven mittens, and brown debris was observed on the kitchen prep floor, including under the refrigerator, freezers, and pan/pot storage. During the same observation, Dietary aide B, Dietary C, and [NAME] D were observed with loose hair hanging from the front and back of their hair restraints while preparing meals. Later, the Maintenance Supervisor entered the kitchen without a beard restraint while assessing kitchen equipment. He stated he should have worn a beard restraint, said he was in a rush to look at the refrigerator and forgot, and acknowledged that wearing a beard restraint would help prevent hair from falling into food. The DM stated that staff were responsible for cleaning the kitchen and that she expected the kitchen to be cleaned after each meal service at a minimum, and she said the fryer, baking sheets, pots, and skillets should be free of debris, grease, and buildup. The dishwasher was also observed with an internal temperature starting at 80 degrees Fahrenheit and ending at 110 degrees Fahrenheit after 3 attempts. The DM stated the dishwasher temperature must be at the manufacturer's recommendation of 120 degrees for dishes to be sanitized and that the chemicals used require the water in the dishwasher to be at a minimum of 120 degrees. Record review showed the manufacturer's recommendation required water temperature to be at least 120 degrees for dishes to be sanitized, and the facility policy stated that the food service area shall be maintained in a clean and sanitary manner and that dishwashing machines must be operated according to specified temperature requirements.
Kitchen Pest Control Program Not Effective
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the kitchen free of pests and rodents. During an observation of the kitchen on 02/02/2026 at 11:16 a.m., while lunch meal preparation was underway, surveyors observed approximately one dime-sized light brown roach crawling from the stove area to where pan sheets were stored. During a second observation on 02/03/2026 at 11:00 a.m., surveyors observed approximately a half-quarter-inch roach crawling on the shelf above where food was being pureed. The DM removed the roach with a napkin and discarded it. During interview on 02/03/2026, the DM stated the facility had a roach issue in the past and said it had gotten better. She stated the facility had regular pest control services for general pests and insects and acknowledged that roaches in the kitchen could potentially get residents sick. The Administrator stated pest control came routinely every 2 weeks and as needed, and that staff were responsible for notifying him if pests or insects were seen so he could call pest control outside the scheduled visits. Record review showed the pest control company visited every two weeks, with the last visit on 01/05/2026, when the kitchen was treated for general pests and the report noted no issues at that time. The facility policy stated kitchen and dining areas shall be kept clean, free from litter and rubbish, and protected from rodents, roaches, flies, and other insects.
Care Plan Not Updated for Resident’s Diet Preferences
Penalty
Summary
The facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for Resident #42, specifically failing to complete a comprehensive care plan for her diet preferences after the Dietitian’s initial assessment on 12/19/2025. Resident #42 was a [AGE]-year-old female admitted with diagnoses including myocardial infarction, generalized muscle weakness and lack of coordination, depression, and heart failure. Her Quarterly MDS showed a BIMS score of 15, indicating intact cognition. The care plan revised 01/15/2026 did not list a diet or vegetarian preference, even though her food allergies were documented as chamomile, chocolate, eggplant, potato, lanolin, [NAME] oil, and lemon flavoring. Record review showed the order summary dated 02/04/2026 listed a regular diet with regular texture and thin consistency, while also showing a cardiac diet order in place since 12/08/2025. A social service progress note dated 12/29/2025 documented a family complaint that the resident’s dietary restrictions and wishes were not being honored and that her diet was not complete or nutritious enough. The Dietitian’s initial assessment note dated 12/19/2025 stated the resident was vegetarian and that DM had a detailed list of likes, dislikes, and food intolerances, with the diet and plan of care to continue. A separate list signed by DM documented food likes, dislikes, and allergies, including no meat, no potatoes, no chocolate, no rosemary, and no tomatoes, along with a note to pick multiple items for meals.
Failure to Honor Resident Dietary Preferences
Penalty
Summary
The facility failed to provide Resident #42 with a nourishing, palatable, well-balanced diet that reflected her dietary preferences. Resident #42 was a cognitively intact female with diagnoses including myocardial infarction, generalized muscle weakness and lack of coordination, depression, and heart failure. Her record showed a vegetarian diet in the dietician’s initial assessment, and the dietician documented that she was vegetarian and had a detailed list of likes, dislikes, and food intolerances. However, the care plan revision and physician order summary did not list a vegetarian diet, and the meal tray card listed a cardiac/renal diet instead. Record review showed Resident #42 had a written and signed list of foods she liked, disliked, and was allergic to, including items such as grilled cheese, puddings, vegetables, beans, rice, cornbread, eggs, tuna, salmon, impossible burgers, mac and cheese, and black beans, along with no meat and no potatoes. A social services progress note documented a family complaint that her dietary restrictions and wishes were not being honored. During observation, she was served meals such as plain shredded lettuce with corn chips, green beans, fruit, and juice, and on another occasion raw broccoli with ice cream and juice, and a separate tray with brussels sprouts only. Resident #42 stated she had repeatedly told staff what she could and could not eat and said her family had to bring food because she had gone hungry when served items she would not eat. During interviews, the DON stated the meal Resident #42 received did not meet expectations and should never have been served as plain lettuce with corn chips. The DON said she knew the resident did not eat meat but would eat salmon and tuna, and the Administrator stated the vegetarian diet was a preference rather than a physician-ordered diet. The Dietician stated Resident #42 had asked for a vegetarian diet, would eat tuna and salmon, and that she had verbally educated the DM on how to accommodate residents on that diet. The facility policy stated food preferences should be assessed, documented, and communicated, and that residents who are unhappy with their diet should have a care plan they are satisfied with and agree to comply with.
Food Handler Certificates Not Current for Dietary Staff
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. Based on interview and record review, 5 of 9 dietary staff reviewed did not have current food handler's certificates until surveyor intervention on 02/02/2026, including Cook-A and Dietary Aides B, C, D, and E. Record review on 02/04/2026 showed that these staff members had hire dates ranging from 11/07/2024 to 11/1/2018, 10/14/2024, 07/15/2025, and 07/19/2024, respectively, and their food handler's certificates were dated 02/02/2026. During an interview on 02/02/2026 at 1:10 p.m., the DM stated she could not produce food handler licenses for Cook-A, Dietary Aide B, Dietary Aide C, Dietary Aide D, and Dietary Aide E that had been issued before 02/02/2026. She said the employees could not remember their passwords to access their licenses online and that she did not have paper copies because she knew they had one. She also stated that she was responsible for ensuring the food handlers were current. Review of the Texas Food Code indicated that all food employees must successfully complete an accredited food handler training course within 30 days of employment.
Stove Burners Failed to Ignite
Penalty
Summary
The facility failed to maintain the stove in safe operating condition when the rear 2nd, 3rd, and 5th burners would not ignite when the knobs were turned on until the 3rd try during an initial tour observation on 02/02/2026 at 9:18 a.m. During the observation, no smell of gas was noted by staff, the pilot light remained on, and the front burners were working. In interviews, the DM stated she was not aware the rear burners were not lighting because staff had cooked on them that morning and said there had been no prior issues with the stove. The Administrator also stated he was not aware the burners were not igniting and had not received any reports that the oven was igniting. The record review showed the facility policy required food service equipment to be kept clean and maintained in good repair.
Incomplete OOH-DNR Form for Resident with DNR Status
Penalty
Summary
The facility failed to ensure Resident #51’s right to formulate an advance directive was provided because her Out-of-Hospital Do Not Resuscitate (OOH-DNR) form was not validly completed. Resident #51 was admitted and readmitted with diagnoses including dementia, dysphagia, dysphasia, osteoarthritis, and muscle weakness. Her record showed DNR status, and her quarterly MDS indicated she had severely impaired cognition, unclear speech, was rarely or never able to make herself understood, and was unable to be interviewed. Her care plan and physician orders also reflected DNR status. Record review of the OOH-DNR form showed the date of birth section was blank, the adult child box in the qualified relative section was checked and signed, but the witness section was incomplete. Witness #2 signed and dated the form two years before the qualified relative signature, and the bottom of the form, which stated that all persons who signed above must sign below to acknowledge the document was properly completed, was not signed by witness #1 or witness #2. During interview, the SS E stated she did not know the witnesses had to sign the bottom of the form and acknowledged that if the form was not completed correctly it was null and void. The DON stated the advance directive should have been completed thoroughly and that the incomplete OOH-DNR meant Resident #51 would be considered full code.
Discharge Planning Not Included in Care Plan
Penalty
Summary
The facility failed to ensure development and implementation of an effective discharge planning process that focused on the resident’s discharge goals for Resident #15. Record review showed the resident was admitted with diagnoses including dementia, cerebral infarction, memory deficit following a stroke, COPD, and prostate cancer. His admission MDS indicated a BIMS score of 07, severe cognitive impairment, partial to moderate assistance needed for toileting and bathing, independent mobility, and disorganized thinking. The MDS also noted active discharge planning to return to the community, with no referral made to the local contact agency because the resident declined referral. The resident’s care plan, revised 10/22/2025, identified a risk for elopement but did not include a developed or implemented discharge plan or interventions related to discharge goals, resident preference, or potential for future discharge. A physician order dated 01/30/2026 indicated the resident was okay for discharge to home/community. Psychosocial assessments documented that the resident’s expectation was discharge to the community or another facility, and comments noted he was admitted for long-term placement but the family had a goal to take him home if able. Another psychosocial assessment documented active plans for the resident to return to the community, that discharge was a feasible goal, and that a referral was made. During interview, the resident and family member stated the plan was to discharge home with the family member providing supervision and monitoring, and that they had participated in care plan meetings and discussions with facility staff about safe discharge. Staff interviews confirmed the discharge had been delayed while awaiting paperwork and approval for home health and a safe discharge assessment. The MDS Coordinator stated discharge should have been included in the comprehensive care plan and was unsure how it was missed. The DON stated the facility wanted the resident to remain for 180 days without elopement issues before discharge to the home/community and acknowledged that discharge plans were required to be on the care plan.
Missing PICC Line IV Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #45 that addressed PICC line IV care. Resident #45 was admitted with diagnoses of urinary tract infection and mycoplasma pneumonia, and the quarterly MDS assessment dated 12/09/2025 indicated intact cognition with a BIMS score of 15. The care plan dated 11/12/25 did not include care plans for PICC line dressing care, flushing, or IV antibiotic therapy. A physician order dated 01/28/26 directed Sodium Chloride 0.9% solution 50 ml with Cefepime 2 gm to be injected into the vein every 12 hours for 3 days for mycoplasma pneumonia, but there were no orders for PICC line flushes. The MAR/TAR dated 01/26 also had no documentation showing PICC line dressing care, flushes, or IV antibiotic administration. During interviews, the MDS nurse stated the care plan should have been revised when the IV antibiotic order was obtained and confirmed there were no care plans related to the IV or flushing. The DON stated there should have been a care plan for the PICC line with interventions for flushing before and after the IV antibiotic, dressing changes, and assessment for signs and symptoms of infection, and the Administrator stated the expectation was that care plans be in place to ensure staff were doing the care correctly.
Missing PICC Flush Orders for IV Antibiotic Administration
Penalty
Summary
The facility failed to provide safe, appropriate administration of IV fluids for Resident #45 by not having orders in place for PICC line flushing before and after medication administration. Resident #45 was a cognitively intact female admitted with diagnoses of urinary tract infection and mycoplasma pneumonia. Her physician order dated 01/28/26 included Sodium Chloride 0.9% solution 50 ml with Cefepime 2 gm, to be injected into the vein every 12 hours for 3 days, but the record did not contain orders for PICC line flushes. The resident’s care plan also did not include care plans for PICC line dressing care, flushing, or IV antibiotic therapy. Review of the MAR/TAR showed no documentation for administering PICC line dressing flushes or IV antibiotic administration. During interview, the LVN stated the PICC line should be flushed before connecting the IV to ensure patency and prevent clogging, and confirmed there were no orders for flushing or dressing changes. The DON stated there should be an order for flushing the PICC line before and after the IV antibiotic, as well as orders for dressing changes and assessment for signs and symptoms of infection, and said everything done for the resident should have orders. The facility policy on Central Venous and Midline Catheter Flushing stated catheters are to be flushed at regular intervals and before and after medication administration.
Unsecured Bedside Medications
Penalty
Summary
The facility failed to ensure all drugs were stored in a locked compartment and accessible only by authorized personnel for one resident. Resident #37, a male admitted on 10/03/25 with allergic rhinitis and a BIMS score of 9 of 15, had an opened 9 ml bottle of Nyquil liquid and an opened bottle of Chloraseptic spray at his bedside. The medications were observed on the bedside nightstand and bedside table during the initial tour and again later the same day, and neither bottle had a pharmacy label. The resident’s electronic record showed no care plan addressing bedside medication storage and no care plan for self-administration of medications. There was also no Self-Administration Medication Assessment completed, and the consolidated physician orders for January and February 2026 contained no scheduled or PRN orders for Nyquil, Chloraseptic spray, self-administration, or bedside storage. During interview, the resident stated his family member brought the medications to him about 3 to 4 weeks earlier, that he used Nyquil at night for a cough and Chloraseptic for a sore tooth, and that he had not reported the medications to nursing staff because they were over-the-counter products. Staff interviews confirmed the medications should not have been left at the bedside without an order or self-administration assessment. The DON stated she was aware of the medications at the bedside and confirmed there was no order and no self-administration assessment for the resident. The resident’s RP stated she brought the medications in and had not notified the facility because she did not know she needed to report over-the-counter medications. The facility policy stated all drugs and biologicals are to be stored in locked compartments, and the pharmacy policy required staff to report unauthorized bedside medications to the charge nurse.
Improper Transfer Results in Resident Injury Due to Failure to Follow Care Plan
Penalty
Summary
A deficiency occurred when a resident who required moderate assistance with transfers, including the use of a mechanical lift and two-person assistance as specified in his care plan, was improperly transferred by a CNA. The CNA manually transferred the resident multiple times without the mechanical lift, using either a gait belt or lifting the resident under his arms, despite the resident's care plan and facility policy requiring mechanical lift use. The improper transfer resulted in the resident sustaining extensive bruising across the chest and multiple rib fractures, as confirmed by medical assessment and imaging. The resident, who had a history of dementia, mobility issues, and previous sternal fracture, was found with significant bruising and a skin tear after the transfers. Interviews with the resident, his family member, and facility staff revealed that the CNA did not follow the prescribed transfer method and that similar improper transfers may have occurred previously. The resident and his family had reported discomfort and pain during these manual transfers, and the family member witnessed the CNA lifting the resident under his arms instead of using the mechanical lift. Facility records and staff interviews confirmed that the resident's care plan had been updated months prior to require mechanical lift transfers with two staff members due to his decline. The CNA involved admitted to transferring the resident without the mechanical lift on the day of the incident, citing the unavailability of the lift pad and the resident's recent decline. Other staff and the DON confirmed that the resident should have been transferred only with a mechanical lift and two-person assistance, and that failure to follow these procedures could result in injury.
Failure to Implement Person-Centered Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for a resident with a history of falls and significant medical conditions, including traumatic subarachnoid hemorrhage, hemiplegia, and convulsions. After the resident experienced a fall resulting in a hip fracture, a care plan conference was held with the resident, family, and facility staff, where specific interventions were agreed upon, such as a therapy evaluation for wheelchair safety, dropping the wheelchair seat, and adding non-skid material to the wheelchair. These interventions were documented in the care plan but were not carried out as intended. Interviews and record reviews revealed that the therapy evaluation was not completed due to the resident's private pay status and lack of funding approval, and the wheelchair seat was not dropped nor was non-skid material added. Staff members, including the LVN and MDS Coordinator, confirmed that these interventions were not implemented, and the MDS Coordinator was unsure how these care plan items were missed. The DON stated that a restorative nursing plan was initiated after the resident returned from the hospital, but the specific interventions discussed in the care plan meeting were not provided prior to the resident's hospitalization. The administrator acknowledged the importance of following care plan interventions decided by the interdisciplinary team but confirmed that the therapy evaluation and related safety interventions were not completed before the resident's hospital transfer. The facility's own policy requires the development and implementation of a comprehensive care plan with measurable objectives and timeframes to meet each resident's needs, but this was not followed in this case.
Failure to Notify Residents of Meal Substitutions
Penalty
Summary
The facility failed to adhere to the planned menu for lunch meals on two consecutive days, which was observed and confirmed through interviews and record reviews. On the first day, fried chicken was scheduled but was substituted with fajita chicken without informing the residents. On the following day, Salisbury steak was supposed to be served, but instead, sliced roast beef was provided, again without notifying the residents of the substitution. This lack of communication and deviation from the planned menu was confirmed by the Dietary Manager, who stated that the substitutions were made due to supply issues but were not communicated to the residents. Several residents expressed dissatisfaction with the meals served, noting that the substitutions did not meet their expectations or preferences. One resident mentioned that the meat served did not resemble any Salisbury steak they had eaten before, while another resident stated they did not eat the meat because it was not appetizing. The Dietary Manager admitted that substitutions were not displayed or communicated to the residents, and the Director of Nurses and the Administrator both expressed expectations that residents should be informed of menu changes. The facility's policy on menus and substitutions did not address the notification of meal substitutions, contributing to the deficiency.
Deficiencies in Kitchen Sanitation Practices
Penalty
Summary
The facility was found to have several deficiencies in its kitchen sanitation practices. During an observation, it was noted that chicken was being improperly thawed on a stovetop in hot water while still in its plastic packaging, which is against professional standards for food safety. Additionally, several food items, including tater tots, shredded lettuce, iceberg lettuce, cheese, and an unknown food item, were not labeled or dated, which is necessary to ensure food safety and prevent spoilage. The kitchen stove was also observed to have a buildup of carbon, grease, and food particles, indicating a lack of regular cleaning and maintenance. Interviews with the Dietary Manager, Director of Nurses, and the Administrator confirmed that these practices were not in line with the facility's policies or professional standards. The Dietary Manager acknowledged that improper thawing and lack of labeling could lead to foodborne illnesses. The Director of Nurses and the Administrator both expressed expectations that kitchen staff should adhere to proper thawing methods, label and date food items, and maintain cleanliness in the kitchen to prevent risks to residents. The facility's documents from 2019 outlined the correct procedures for meat and vegetable preparation and general kitchen sanitation, which were not being followed as observed during the survey.
Failure to Provide Catheter Privacy Bag
Penalty
Summary
The facility failed to uphold the dignity and respect of a resident by not providing a catheter privacy bag while the resident was in communal areas. The resident, a female with severe cognitive impairments and dependent on assistance for all activities of daily living, was observed on multiple occasions with her catheter bag exposed in both her room and the main living room. This lack of privacy was noted during observations on two consecutive days, where the catheter bag was visible to staff and other residents. Interviews with staff, including a CNA, LVN, ADON, DON, and the administrator, revealed a consensus that catheter privacy covers should be used to maintain resident dignity. The staff acknowledged that the absence of a privacy cover could lead to embarrassment for the resident and discomfort for others. It was noted that the facility had privacy covers available, and it was the responsibility of the nursing staff to ensure their use, especially when residents returned from the hospital with different catheter setups. The facility's policies on catheter use and resident dignity emphasized the importance of using drainage bag holders or covers when residents are out of their rooms to maintain dignity. Despite these policies, the facility did not adhere to them in the case of this resident, leading to a deficiency in maintaining the resident's dignity and quality of life.
Failure to Address Sensory Deficits in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, addressing their specific medical and sensory needs. Resident #6, a female with dementia and cognitive communication deficit, had moderately impaired vision and used corrective lenses. However, her care plan did not address her vision impairment or the use of eyeglasses. Observations revealed that Resident #6 was often without her eyeglasses, which were found in her purse by the DON, indicating a lack of consistent monitoring and support for her vision needs. Resident #29, a male with dementia and moderate cognitive impairment, had moderate difficulty hearing and did not use hearing aids. His care plan also failed to address his hearing impairment. During interactions, it was noted that Resident #29 had difficulty understanding questions unless spoken to loudly and slowly. Despite acknowledging his hearing difficulty, Resident #29 refused hearing aids, and the facility had not effectively incorporated this into his care plan. Interviews with facility staff, including the MDS Coordinator and DON, confirmed that the residents' sensory deficits should have been included in their care plans. The MDS Coordinator admitted to being unaware of Resident #29's hearing issues, while the DON emphasized the importance of addressing these deficits to ensure proper communication and prevent risks such as falls. The facility's policy required individualized care plans consistent with medical assessments, which were not adhered to in these cases.
Failure to Document and Administer Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for Resident #12, who was at risk for developing pressure ulcers due to severe cognitive impairment and existing pressure ulcers. The resident's care plan required the application of Venelex ointment twice daily, as per the hospital discharge summary. However, the facility did not document the administration of this treatment on the evening shifts of 10/19/24 and 10/20/24, indicating a lapse in following the prescribed treatment regimen. Interviews with the facility staff, including the Wound Care Nurse (WCN), Licensed Vocational Nurses (LVNs), and the Director of Nursing (DON), revealed inconsistencies in the documentation and execution of wound care treatments. The WCN stated that the treatment should be documented in the Medication Administration Record (MAR) and Treatment Administration Record (TAR) to ensure it was completed. However, the MAR/TAR for Resident #12 showed no initials for the evening shifts on the specified dates, despite nurse's notes indicating the dressings were intact. The weekend supervisor, RN H, acknowledged that if treatments were not documented, they were considered not done. The facility's Pressure Ulcer Treatment policy mandates that residents with pressure ulcers receive necessary treatment to promote healing and prevent infection. Despite this policy, the facility's staff interviews and record reviews highlighted a failure to adhere to the treatment orders, potentially compromising Resident #12's wound healing process. The DON and Administrator emphasized the importance of following physician orders and documenting treatments, yet the deficiency in care persisted, as evidenced by the lack of documentation for the evening treatments on the specified dates.
Failure to Change Catheter and Bag as Ordered
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, specifically in changing the catheter bag and supra-pubic catheter as ordered. The resident, a male with a history of dementia, urinary retention, and obstructive uropathy, was at risk for urinary tract infections. The care plan required the foley catheter bag to be changed twice a month and the supra-pubic catheter to be changed every four weeks. However, the Treatment Administration Record (TAR) indicated that these changes were not performed on the scheduled dates, with the catheter bag and supra-pubic catheter being changed on the 20th instead of the 15th and 16th, respectively. Interviews with nursing staff revealed inconsistencies in following the physician's orders. LVN J mentioned that the resident's catheter bag was changed more frequently due to leaks or the resident's attempts to empty it himself, but acknowledged the importance of adhering to the schedule to prevent infections. The Director of Nursing (DON) expected staff to follow orders and document any deviations, emphasizing the risk of infection if the catheter and bag were not changed as ordered. However, the facility's policy on indwelling urinary catheter use did not address the frequency of changing the bag or catheter. Additional interviews highlighted potential systemic issues, such as locked supplies during night shifts and weekends, which could prevent timely changes. The Administrator noted that charge nurses were responsible for documenting catheter changes, but there was a lack of clarity on the risk of infection if changes were delayed. The facility's failure to ensure timely catheter and bag changes placed the resident at risk for developing infections.
Failure to Maintain Safe Food Storage in Resident's Personal Refrigerator
Penalty
Summary
The facility failed to maintain safe and sanitary storage of food items in a resident's personal refrigerator, specifically for a resident who had a tendency to hoard food and other items. The resident, who was cognitively intact and independent with most activities of daily living, had expired food items in her refrigerator, including milk cartons with past expiration dates. Despite having a care plan in place for staff to remove old food and trash daily, the expired items were not removed, posing a risk for foodborne illnesses. Interviews with facility staff revealed inconsistencies in the responsibility and frequency of cleaning residents' personal refrigerators. The Hospitality Aide was identified as responsible for checking and cleaning the refrigerators daily, but there was confusion among staff about the frequency and responsibility for this task. Some staff members, including CNAs and the ADON, were unsure of the cleaning schedule, and there was no documentation of attempts or refusals to clean the refrigerator, despite the resident's known behavior of hoarding. The facility's policy on personal refrigerators required daily checks for expired food and weekly cleaning, but this was not adhered to in practice. The DON acknowledged that the resident did not like her refrigerator to be touched, and there was no documentation of the resident's refusal to allow cleaning. The ADM emphasized the importance of removing expired food to prevent foodborne illness, but the lack of documentation and adherence to policy contributed to the deficiency.
Infection Control Deficiency in Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically in the case of a resident with a pressure ulcer on the coccyx. The resident, who had severe cognitive impairment and was at risk of developing pressure ulcers, did not have the necessary signage or personal protective equipment (PPE) outside her door to indicate she was on Enhanced Barrier Precautions (EBP). This oversight occurred on two consecutive days, despite the resident's condition requiring such precautions to prevent the spread of infection. Additionally, a wound care nurse did not adhere to the facility's EBP policy by failing to wear a gown during the resident's wound care. Interviews with the wound care nurse and the Director of Nursing (DON) revealed a lapse in following the EBP guidelines, which are crucial for preventing cross-contamination and infection spread. The DON admitted to forgetting to place the resident on EBP after removing her from contact isolation for a previous C. difficile infection. The facility's policy mandates the use of gowns and gloves during high-contact care activities, such as wound care, to prevent the transfer of multidrug-resistant organisms (MDROs).
Facility Fails to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, as evidenced by incidents involving a Certified Nursing Assistant (CNA) and a Dietary Aide (DA). In the first incident, a CNA was reported to have verbally and physically abused a male resident with dementia and moderately impaired cognition. The resident, who was non-interviewable, was allegedly hit on the head by the CNA after being verbally threatened. This incident was witnessed by another CNA, who reported the abuse to the Assistant Director of Nursing (ADON). The resident showed no signs of emotional distress or physical injury, but the incident was considered abuse by the facility's Director of Nursing (DON). In the second incident, a female resident with intact cognition and a history of mental health disorders reported verbal abuse by a DA. The resident claimed that the DA used foul language towards her in the smoking area after she complained about cold food. This account was corroborated by a witness, a new CNA, who heard the DA cussing at the resident. The DA denied the allegations but was suspended and later terminated. The facility's investigation confirmed the abuse allegation, and the DON acknowledged that cussing at a resident constituted verbal abuse. Both incidents highlight the facility's failure to ensure a safe environment free from abuse for its residents. The facility's Abuse and Neglect Prohibition Policy clearly defines verbal and physical abuse, yet these incidents occurred, indicating a lapse in adherence to the policy. The facility's administration took steps to investigate and address the incidents, but the deficiencies were noted by surveyors as part of their review.
Failure to Report Abuse in a Timely Manner
Penalty
Summary
The facility failed to implement its written policies and procedures prohibiting mistreatment, neglect, and abuse of residents, as evidenced by two separate incidents involving two residents and two staff members. In the first incident, a CNA witnessed another CNA physically and verbally abusing a resident by hitting him on the head and threatening him verbally. The witness delayed reporting the incident due to fear of the perpetrator, which was against the facility's policy requiring immediate reporting of abuse to the administration. In the second incident, a dietary aide verbally abused a resident by cussing at him during an argument about the resident's food. A new CNA witnessed the incident but did not report it immediately, as she did not recognize it as abuse due to the resident's own aggressive behavior. The facility's policy mandates that all suspected abuse be reported immediately, regardless of the circumstances. Both incidents highlight a failure in the facility's staff training and understanding of abuse reporting protocols. The staff involved had signed acknowledgments of understanding the abuse policies, yet failed to act in accordance with them. This lack of immediate reporting could place residents at risk for further abuse and an unsafe environment.
Failure to Report Abuse Timely
Penalty
Summary
The facility failed to ensure that all alleged violations involving mistreatment, neglect, abuse, or misappropriation of resident property were reported immediately, as required by regulations. Specifically, the facility did not report incidents involving two residents and two staff members within the mandated two-hour timeframe. In the first incident, a CNA witnessed another CNA physically and verbally abusing a resident but delayed reporting the incident for five days due to fear of the perpetrator. The resident involved had dementia and was non-interviewable, and the incident was not reported until the witness felt safe to do so. In the second incident, a dietary aide verbally abused a resident in the smoking area, witnessed by a new CNA who did not report the incident immediately. The resident, who had a history of mental health conditions, reported the incident to the administrator four days later. The dietary aide was suspended and later terminated after the facility confirmed the abuse allegation. The witness did not recognize the incident as abuse due to the resident's behavior during the altercation. Both incidents highlight a failure in the facility's reporting system, where staff did not report abuse immediately as required. The facility's policy mandates immediate reporting of abuse to the administrator, DON, and ADON, but this was not adhered to in these cases. The delay in reporting could have placed residents at risk for continued abuse, as noted in the findings.
What surveyors are citing around you — mapped
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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 112 citations issued within 25 miles in the last 12 months — including the 7 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 Nursing & Rehabilitation Center | 0.1 mi | ★★★★★ | 0 | 0 |
| Heritage House Of Marshall Health & Rehabilitation | 4.2 mi | ★★★★★ | 3 | 0 |
| Avir At Jefferson | 16.4 mi | ★★★★★ | 16 | 0 |
| Whispering Pines Lodge | 19.7 mi | ★★★★★ | 34 | 7 |
| Treviso Transitional Care | 20.3 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.