Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 North Shore Healthcare At Marshfield during CMS and state inspections, most recent first.
A resident did not receive appropriate care for existing pressure ulcers, and preventive measures to avoid new ulcers were not consistently implemented. The facility did not follow established protocols for assessment, monitoring, and treatment of pressure ulcers.
A resident admitted with a surgical incision and later diagnosed with a stage 3 pressure injury was not accurately represented in the MDS assessments. The admission MDS did not document the surgical wound or related care needs, and the discharge MDS failed to record the unhealed pressure injury, despite clinical documentation and staff confirmation that these should have been included.
A resident with a surgical incision, MASD, and mild risk for pressure injuries was admitted without a complete baseline care plan addressing their impaired skin integrity or necessary interventions. Despite assessments indicating these risks and conditions, the care plan was not updated to include them until the resident's last day, resulting in missed documentation and interventions for wound care and pressure injury prevention.
A resident with moderately impaired cognition and multiple medical conditions was found to have bed side rails in use without a documented assessment for entrapment risk or informed consent from their POA, as required by facility policy. The absence of these steps was confirmed by the NHA.
A CNA did not perform hand hygiene after removing soiled gloves during incontinence care for a resident, subsequently touching the resident and a tube of barrier cream with unclean hands. This action was in direct violation of the facility's hand hygiene policy, as confirmed by both the CNA and the DON during interviews.
The facility did not ensure required background checks were completed for staff, including a RN who was hired without an out-of-state background check despite having recently lived in another state. The deficiency was not identified during hiring or a subsequent audit, and another CNA worked a shift with an expired background check before the issue was discovered.
A resident with a history of heart failure and other conditions was not weighed on three occasions and experienced significant weight gains without physician notification, contrary to care plan orders. The facility failed to adhere to the resident's weight monitoring and notification requirements, as confirmed by the ADON.
The facility failed to consistently follow smoking interventions for two residents, leading to a deficiency in maintaining a safe environment. One resident was observed with smoking materials in their room, contrary to the care plan requiring storage at the nurses' station. Another resident kept their smoking materials despite the care plan's directive. The facility's smoking policy was not effectively implemented, as confirmed by staff interviews and observations.
A resident with a history of UTIs was observed with a catheter drainage bag and tubing dragging on the floor, contrary to proper catheter care practices. The facility's policy did not address the correct positioning of catheter equipment, and staff confirmed that such equipment should not touch the floor.
A resident with severe cognitive impairment and multiple medical conditions did not receive prescribed enteral feedings due to a failure in communication between CNAs and nurses. The CNAs documented meal intake but did not notify nurses, who were responsible for administering supplemental feedings based on the resident's intake. This resulted in the resident missing several supplemental feedings as ordered by the physician.
The facility failed to ensure safe medication administration for two residents, who were found with medications at their bedsides without physician orders or self-administration assessments. Despite having intact cognition, both residents lacked necessary orders and care plans for self-administration and bedside storage, leading to a deficiency in adherence to facility policies.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews that indicated lapses in the assessment, monitoring, and treatment of pressure ulcers for residents at risk. The report notes that necessary interventions to prevent skin breakdown were not consistently applied, and existing pressure ulcers were not managed according to established protocols.
Inaccurate MDS Assessments for Surgical Wound and Pressure Injury
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for a resident who was admitted with a surgical incision and later developed a stage 3 pressure injury. Upon admission, the resident had a surgical incision on the lower back, as documented by physician orders and care instructions, but the admission MDS assessment did not reflect the presence of a surgical wound, the need for surgical wound care, or the use of pressure-reducing devices. The assessment also did not indicate that the resident was on a turning or repositioning program, despite being at risk for pressure injuries and requiring moderate assistance with mobility. Subsequently, a wound clinic note documented a stage 3 sacral pressure injury, but the discharge MDS assessment failed to record the presence of this unhealed pressure injury. Interviews with the DON and MDS RN confirmed that both the surgical incision and the pressure injury should have been documented in the respective MDS assessments. The inaccuracy in the MDS assessments was identified through staff interviews and record review, demonstrating a failure to follow the facility's policy for conducting accurate resident assessments.
Failure to Develop Timely Baseline Care Plan for Resident with Skin Integrity Issues
Penalty
Summary
The facility failed to develop a complete baseline care plan within 48 hours of admission for a resident who had a surgical incision and was at risk for pressure injury. Upon admission, the resident had multiple diagnoses including post-surgical orthopedic aftercare, diabetes, heart failure, and chronic kidney disease, and was assessed as having moderately impaired cognition. Medical records and assessments indicated the presence of a surgical incision, moisture-associated skin damage (MASD), and a mild risk for developing pressure injuries. Despite these findings, the baseline care plan did not document the resident's impaired skin integrity, surgical incision, MASD, or include any interventions for treatment and prevention of pressure injuries. Further review showed that the resident's plan of care was not updated to reflect these conditions until the last day of their stay, even though weekly skin assessments and hospital discharge paperwork documented the development of a decubitus ulcer and a stage 3 pressure injury. Staff interviews confirmed that information from the skin section of the MDS assessment should have been incorporated into the care plan, but this was not done in a timely manner. The lack of a comprehensive baseline care plan resulted in the omission of necessary interventions to address the resident's immediate needs related to skin integrity and wound care.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to assess the risk for entrapment, review the risks and benefits, and obtain informed consent for the use of side rails for one resident. The facility's policy requires a side rail assessment to be completed in the electronic medical record, alternatives to be attempted prior to side rail use, and informed consent to be obtained from the resident or their representative if the rail meets the definition of a restraint. However, for a resident with diagnoses including orthopedic after care, vascular dementia, insomnia, use of anticoagulants, weakness, reduced mobility, and rheumatoid arthritis, these steps were not followed. The resident, who had moderately impaired cognition and an activated Power of Attorney (POA), was observed with side rails on their bed. Upon review of the medical record, there was no documentation of a side rail assessment or consent from the POA. The Nursing Home Administrator confirmed that the required assessment and consent were not present for this resident.
Failure to Perform Hand Hygiene After Incontinence Care
Penalty
Summary
During the provision of incontinence care for one resident, a Certified Nursing Assistant (CNA) failed to follow the facility's hand hygiene policy. After providing peri-care and removing soiled gloves, the CNA did not perform hand hygiene or don clean gloves before touching the resident's legs, back, and a tube of barrier cream. This lapse was observed by a surveyor, who noted that the CNA only performed hand hygiene after being questioned about it. The facility's policy, revised in November 2022, requires staff to perform hand hygiene after removing gloves and after handling items potentially contaminated with bodily fluids. The CNA confirmed during an interview that hand hygiene was not completed as required, and the Director of Nursing also acknowledged that the correct procedure was not followed in this instance.
Failure to Complete Required Background Checks for Staff
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation by not ensuring thorough caregiver background checks for staff. Specifically, a registered nurse (RN) was hired without the required out-of-state background check, despite documentation indicating the RN had resided in South Carolina within the previous three years. The omission was not identified during the initial hiring process or during a subsequent audit, as the audit document incorrectly indicated the RN had not resided outside Wisconsin in the last three years. Additionally, the facility's process for monitoring background checks was insufficient, as evidenced by another instance where a certified nursing assistant (CNA) worked a shift with an expired background check. This lapse was only discovered during an audit, after which the CNA's employment ended due to failure to complete the required background check information. These findings demonstrate that the facility did not consistently follow its own policy for screening potential employees and ensuring all required background checks were completed prior to allowing staff to work.
Failure to Monitor and Report Resident's Weight Changes
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practicable physical well-being for a resident, identified as R42, who had specific orders for daily weight monitoring and physician notification if weight increased beyond set parameters. R42, who was not cognitively impaired, had a medical history including COPD, morbid obesity, heart disease, atrial fibrillation, and heart failure. Despite having orders for daily weights and physician notification for significant weight changes, R42 was not weighed on three occasions, and the physician was not notified on three occasions when weight changes exceeded the ordered parameters. The medical record review revealed that R42 experienced several significant weight gains, including a 9-pound increase, without appropriate physician notification or documentation of follow-up actions. The Assistant Director of Nursing confirmed that R42's weight management was overseen by the heart failure clinic and acknowledged the failure to adhere to the weight monitoring and notification orders. This lack of adherence to the care plan and physician orders contributed to the deficiency in maintaining R42's physical well-being.
Failure to Follow Smoking Interventions for Residents
Penalty
Summary
The facility failed to ensure that smoking interventions were consistently followed for two residents, leading to a deficiency in maintaining a safe environment free from accident hazards. Resident 36, who had intact cognition and was responsible for their own medical decisions, was observed to have cigarettes and a lighter in their room, contrary to the care plan that required smoking materials to be stored at the nurses' station. Despite the care plan's requirement for Resident 36 to sign out when going outside to smoke and return smoking materials to the nurses' station, these interventions were not consistently followed. Staff did not enforce the policy, as evidenced by the resident's possession of smoking materials and failure to sign in and out consistently. Similarly, Resident 45, who also had intact cognition, was found to be keeping their smoking materials despite the care plan's directive to store them at the nurses' station. The sign in/sign out log for Resident 45 showed inconsistencies, with the resident signing out on multiple occasions but not consistently signing back in. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that the smoking policy was not being adhered to by staff and residents. The facility's smoking policy, revised in September 2024, outlined the need for supervision and secure storage of smoking materials for residents requiring such interventions. However, the policy was not effectively implemented, as demonstrated by the observations and interviews conducted by the surveyor. The lack of adherence to the smoking policy for both residents indicates a failure to provide adequate supervision and control over smoking materials, which could potentially lead to safety hazards within the facility.
Inadequate Catheter Care for Resident with UTI History
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident, identified as R15, who had a history of urinary tract infections (UTIs) and was diagnosed with a UTI on 3/11/25. On 3/25/25, the surveyor observed R15 in a wheelchair with the catheter drainage bag placed in a pillowcase and attached to the underside of the wheelchair. The pillowcase and catheter tubing were dragging on the floor, which was confirmed by a Certified Nursing Assistant (CNA) who adjusted the tubing but left the pillowcase on the floor. The facility's Catheter Care policy, dated 3/15/23, did not address the proper positioning or placement of catheter tubing or drainage bags. Interviews with a Registered Nurse (RN) and the Director of Nursing (DON) confirmed that catheter bags and tubing should not touch the floor. R15's medical record indicated intact cognition and responsibility for their healthcare decisions, with a history of UTIs and recent treatment with antibiotics.
Failure to Administer Enteral Feedings as Ordered
Penalty
Summary
The facility failed to ensure that enteral feedings were provided as ordered for a resident with severe cognitive impairment and multiple medical diagnoses, including malignant neoplasm of the brain, aphasia, and hemiplegia. The resident had an activated Power of Attorney for Healthcare and was on a specific enteral feeding regimen based on the percentage of meals consumed. The physician's order required supplemental tube feedings to be administered three times a day, with specific amounts based on the resident's meal intake. However, the facility did not administer the required supplemental feedings on multiple occasions, as documented in the resident's medical records and confirmed by staff interviews. The surveyor's review of the resident's medical records and interviews with facility staff revealed that the Certified Nursing Assistants (CNAs) documented the resident's meal intake but failed to notify the nurses, who were responsible for determining and administering the necessary supplemental feedings. The Director of Nursing confirmed that the CNAs should have informed the nurses of the resident's meal intake, and the nurses should have administered the correct amount of feeding. This oversight resulted in the resident not receiving the prescribed enteral supplements on several documented dates.
Medication Administration and Storage Deficiency
Penalty
Summary
The facility failed to ensure the accurate and safe administration of medication for two residents, R38 and R156, as observed by the surveyor. R38 was found with a bottle of Deep Sea Saline Solution at the bedside without a physician's order or an order to self-administer medication. Despite having intact cognition, R38's medical record indicated an inability to self-administer medication, and there was no care plan for self-administration or bedside medication storage. RN-G admitted to providing the saline solution without ensuring a physician's order and later obtained an order after the surveyor's inquiry. Similarly, R156 was observed with multiple medications at the bedside, including Remedy antifungal powder and Incruse Ellipta inhalation powder, without appropriate physician orders or self-administration orders. Although R156 had intact cognition, the medical record indicated an inability to self-administer medication, and there was no care plan for self-administration or bedside medication storage. The Director of Nursing and other staff confirmed the lack of adherence to the facility's medication administration and storage policies. The facility's policies require physician orders for all medications and assessments to determine residents' ability to self-administer medications. Both residents lacked the necessary orders and assessments, leading to the deficiency. The nursing staff, including RN-G and RN-H, acknowledged the oversight and the need for adherence to the facility's policies, as confirmed by the Director of Nursing and the Nursing Home Administrator.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Marshfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Norwood Health Ctr-central | 2.3 mi | ★★★★★ | 2 | 0 |
| Three Oaks Health Services | 3.3 mi | ★★★★★ | 9 | 0 |
| Colonial Health Services | 19.2 mi | ★★★★★ | 2 | 2 |
| Abbotsford Health Care Center | 20.8 mi | ★★★★★ | 7 | 0 |
| Edenbrook Of Wisconsin Rapids | 25.6 mi | ★★★★★ | 1 | 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.