Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Marshall Rehab & Nursing during CMS and state inspections, most recent first.
The facility failed to ensure meals were palatable and served at an appetizing temperature for all 58 residents. A grievance documented complaints of cold food, and surveyors twice observed numerous trays in the main dining room with more than half of the food uneaten. A test tray showed beef stew at 132°F, and the stew and mixed vegetables did not taste warm. A resident reported meals being cold, unappetizing in appearance, and often overcooked, burned, or dried out. Another resident reported usually receiving cold food, including inedible pancakes, and stated that although heating “pucks” were purchased to keep plates warm, they were sometimes not heated or not used by staff. The Administrator acknowledged multiple complaints about cold and poor-tasting food.
Surveyors observed that an in‑kitchen air conditioning unit was leaking water onto the dishwashing area and splashing into the food service area during meal service. During the same meal service, a CDM accidentally knocked multiple paper meal tickets onto the kitchen floor over a several‑foot area, then, with another staff member, picked them up and placed them back on the counter and onto resident meal trays. The CDM later acknowledged that the air conditioner had broken and was dripping condensate in the kitchen and that the meal tickets were contaminated when they touched the floor, yet they were still used on trays for residents.
A resident who was moderately cognitively intact and incontinent, requiring assistance with toileting and personal hygiene, did not receive incontinence care for several hours while seated in a wheelchair, despite having physician orders for regular coccyx wound treatment. During observed wound care, an LPN collected wound supplies by holding them against her jacket and placed them on an un-disinfected bedside table, later acknowledging this contaminated the supplies. The resident’s coccyx wound, previously smaller, was observed as an open, red area about the size of a quarter with non-blanchable peri-wound tissue and an additional line-shaped open wound, while the wound nurse reported not being aware of the wound’s worsening or the new area. The DON stated that staff are expected to provide incontinence care every two hours and as needed, along with preventative measures such as repositioning and toileting.
A cognitively intact resident who required assistance with toileting and personal hygiene received incontinence care during which CNAs failed to disinfect the bedside table before placing clean washcloths, repeatedly used contaminated gloved hands in a shared basin of wash water, and used a soiled brief to catch additional urine without providing further perineal care. The same contaminated gloves were then used to remove the saturated brief and apply a clean one without hand hygiene or glove change, and no barrier cream was applied, resulting in a failure to prevent cross contamination during incontinence care.
The facility failed to consistently provide hot, palatable meals at safe temperatures to residents receiving room or hall trays. A test tray showed an entrée temperature below the facility’s policy standard and felt cold to the touch, and the grievance log documented complaints about cold food. Several cognitively intact residents who ate in their rooms reported that their meals were frequently or always cold, including specific examples such as cold fries and generally unappetizing food. Multiple CNAs confirmed that residents often complained about cold food, citing lack of heating pucks under plates and delays in meal delivery, while the Dietary Manager acknowledged ongoing issues with maintaining food temperature, particularly with certain items like shoestring fries and with inconsistent use of hot pucks.
Multiple residents with cognitive impairments were involved in physical altercations, including slapping, pushing, and kicking, after unwelcome physical contact from another resident. Staff and other residents reported ongoing issues with inappropriate touching and physical responses, indicating a failure to prevent resident-to-resident abuse.
A resident with severe cognitive impairment and a diagnosis of dementia exhibited ongoing behaviors such as touching other residents, leading to altercations and complaints. The care plan did not address these behaviors, and staff did not recognize them as problematic. Multiple staff members reported not receiving dementia training, and the facility lacked a dementia unit or coordinator.
The facility did not notify law enforcement after multiple incidents where a resident was struck by two different residents and another resident was allegedly sexually assaulted by a visitor. Although internal reports were completed and the state agency was notified, the administrator stated they were unaware of the requirement to contact police, despite facility policy mandating such reporting.
A resident with severe cognitive impairment was physically abused on separate occasions by two other residents with no cognitive impairment. In one case, a resident struck the victim in the face after becoming angry, an act witnessed by staff. In another, a resident forcefully pushed the victim's wheelchair and struck her on the arm in the dining room while staff were not present. Both incidents demonstrate a lack of adequate supervision and failure to prevent peer-to-peer abuse.
After a resident with no cognitive impairment physically assaulted another resident, staff did not remove him from direct access to his severely cognitively impaired, non-verbal, and fully dependent roommate. Despite staff concerns and the facility's policy requiring immediate protective actions after abuse is identified, the administrator instructed staff not to move either resident, leaving the vulnerable roommate at risk.
Two residents' medical records were found incomplete after incidents of physical abuse, with missing documentation of injuries, lack of family and physician notifications, and absence of required 72-hour follow-up assessments. Nursing staff and administration confirmed that documentation did not meet facility policy, resulting in gaps in recordkeeping after the events.
A facility staff member failed to immediately report an allegation of staff-to-resident abuse to the administrator, affecting a resident. The incident was observed by a cook and reported to their manager, who delayed informing the administrator until the next day, contrary to the facility's abuse prevention policy and federal regulations requiring immediate reporting.
A facility failed to identify the root cause of pain for a resident with multiple diagnoses, including a fractured neck of the right femur. Despite severe pain and cognitive impairment, the facility did not conduct a comprehensive pain assessment or attempt other interventions to identify the cause of the pain. The resident continued to experience severe pain, requiring narcotic pain medications, and was later found to have a broken femur head requiring a total hip replacement.
The facility failed to employ a clinically qualified Director of Food and Nutrition Services, with the Dietary Manager admitting to not meeting state standards. Additionally, the dietary staff failed to prevent cross-contamination of food and maintain sanitary storage areas, affecting all 53 residents.
The facility failed to prevent direct cross-contamination of stored food and maintain sanitary food storage areas. Mold was observed on shelving in the kitchen walk-in cooler, and condensation from the walk-in freezer's evaporator/condenser supply lines leaked onto food items. The Dietary Manager confirmed the contamination. The facility housed 53 residents at the time.
The facility failed to ensure residents' rights to dignified activities of daily living, affecting six residents. Residents experienced long wait times for meals and toileting assistance, leading to distress and incontinence. Additionally, a resident with severe cognitive impairment was repeatedly observed in soiled clothing, compromising their dignity and hygiene.
The facility failed to supervise a resident at risk for self-harm and did not document another resident's fall, initiate neurological checks, conduct a fall investigation, determine a root cause, or implement a specific fall intervention. These deficiencies affected two residents reviewed for accidents and supervision.
The facility failed to provide residents with food at an appetizing temperature, with meals often served up to one and a half hours late, resulting in hot food being served cold. The issue persisted despite discussions between the Dietary Manager and nursing staff, and was documented in Resident Council meeting notes for three consecutive months.
The facility failed to provide bedtime snacks for four residents, including two with Diabetes Mellitus, due to the snack cart being placed in the linen room instead of the nurses' station. This made snacks inaccessible to residents, and the issue was not known to the Dietary Manager, ADON, or DON.
The facility failed to follow up on abnormal lab results for a resident with severe cognitive impairment, delaying necessary medication adjustments. Additionally, a CNA improperly administered Zinc Oxide paste, a task reserved for licensed nurses, indicating a lapse in staff training and protocol adherence.
The facility failed to provide timely incontinence care for a resident with moderate cognitive impairment and limited mobility, leading to prolonged periods of sitting in wet briefs and resulting in skin irritation and discomfort. Staff and the resident's roommate confirmed delays in responding to call lights, compromising the resident's dignity and comfort.
The facility failed to follow physician-ordered pressure ulcer treatments and repositioning interventions for a resident with multiple Stage 4 pressure ulcers. The resident was left in a reclined wheelchair for extended periods, causing discomfort, and an LPN did not properly cleanse and dress the wounds as per physician orders.
A facility failed to check the placement of a PEG tube before administering medication and enteral feeding to a resident with severe cognitive impairment and multiple medical diagnoses. The RN did not follow the facility's policy, and the DON confirmed the importance of these checks.
The facility failed to maintain respiratory equipment according to physician orders and facility policy, affecting three residents. Issues included undated oxygen tubing and nasal cannulas, lack of humidifier bottles, and outdated equipment. Staff confirmed these deficiencies during observations.
The facility failed to provide mail service to residents on Saturdays, affecting all 53 residents. Staff confirmed that while mail is delivered by the post office on Saturdays, it remains locked up and inaccessible until Monday, resulting in residents not receiving their mail until the following Monday.
The facility failed to provide a clean, homelike environment for two residents. One resident's bathroom was found with feces on the walls and floor, while another's bathroom had a broken toilet and a strong musty odor. Despite complaints and acknowledgment from the Director of Nurses, the issues were not promptly addressed, highlighting deficiencies in housekeeping and maintenance practices.
A resident with severe cognitive impairment was found with unexplained bruises on their back. The facility's staff did not report the injuries to the State Agency, despite the facility's policy requiring such reports. The Director of Nurses and Administrator acknowledged the failure to report, citing a misunderstanding of the reporting requirements.
Failure to Provide Palatable Meals at Appropriate Temperature
Penalty
Summary
The facility failed to ensure that meals were palatable, attractive, and served at a safe and appetizing temperature, with the potential to affect all 58 residents in the building. A grievance dated 12/1/25 documented that the food was cold. On 2/24/26 at 1:00 PM and again on 2/25/26 at 12:55 PM, surveyors observed numerous resident meal trays sitting in the main dining room with more than half of the food left on each of twelve and fifteen trays, respectively. On 2/25/26 at 1:15 PM, a test tray was obtained and the CDM measured the beef stew at 132°F; the beef stew and mixed vegetables did not taste warm. One resident stated his meal was cold, described the food as looking like “slop,” reported that the food is always cold and does not taste good, and said it is frequently overcooked, burned, or dried out. Another resident stated the food is usually served cold, reported being served cold, inedible pancakes, and noted that although the facility obtained heating “pucks” to place under plates after complaints, the pucks were sometimes not warm or were not used by staff. The Administrator acknowledged awareness of multiple complaints about food being served cold or not tasting good.
Cross Contamination Risk from Contaminated Meal Tickets and Kitchen Condensate
Penalty
Summary
Surveyors identified a deficiency in food service practices related to cross contamination during meal service. The facility census documented 58 residents residing in the facility. During observation of the kitchen, the air conditioning unit mounted inside the kitchen was found to be dripping water onto the dishwashing area and onto the floor, with splashing extending approximately three to four feet into the food service area. This condition was present during active meal service. Later the same day, during meal service, the Certified Dietary Manager (CDM) accidentally knocked resident paper meal tickets off the counter, causing them to scatter over a three to four foot area on the kitchen floor. The CDM, wearing gloves, picked up the paper tickets from the floor and placed them back on the corner of the warmer counter. Another staff member assisted in picking up the tickets and then placed the pile of contaminated meal tickets on resident meal trays to be served. The CDM acknowledged that the air conditioner had broken earlier that morning and was dripping condensate throughout the kitchen, and further acknowledged that the meal tickets became contaminated when they touched the floor and that there was a good chance all of the trays would have been contaminated because the tickets stay with the trays.
Failure to Prevent Cross Contamination and Provide Timely Incontinence Care During Wound Management
Penalty
Summary
Surveyors identified a deficiency in providing appropriate treatment and care according to orders and in preventing cross contamination during wound care for one resident with coccyx wounds. The resident’s MDS documented moderate cognitive intactness and a need for assistance with toileting and personal hygiene, and the POS included an order to apply a hydrocolloid dressing to the coccyx every other day starting 2/23/26. On 2/25/26, the resident remained seated in a wheelchair from 9:00 AM to 1:00 PM without being provided incontinence care, despite being incontinent and requiring assistance. During wound care at 2:35 PM, an LPN gathered wound care supplies (gauze, dressing, scissors, wound cleanser) by holding them against her zip-up hoodie jacket and then placed the supplies on the resident’s bedside table before ensuring the table was disinfected. The previous dressing on the coccyx was a simple foam dated 2/23/26. At the time of the observation, the resident’s coccyx had an open, red wound approximately the size of a quarter with a non-blanchable peri-wound area, and a separate open, red, line-shaped wound approximately an inch long. The LPN acknowledged that she contaminated the resident’s wound care supplies by holding them against her contaminated jacket and stated that the coccyx wound had been the size of a pencil eraser a few days earlier and that the resident previously had no open areas on the right buttock. The wound nurse later stated that staff do not lay the resident down after breakfast as they should and attributed the open areas on the resident’s bottom to this, and also stated she was not aware that the coccyx wound had worsened or that there was a new area on the right buttock. The DON stated that staff are expected to provide incontinence care every two hours and as needed, and to provide preventative care such as repositioning and toileting to prevent wounds, and confirmed that the resident is incontinent and requires assistance with incontinence care.
Failure to Prevent Cross Contamination During Incontinence Care
Penalty
Summary
The deficiency involves failure to prevent cross contamination during incontinence care for one resident who was cognitively intact and required assistance with toileting and personal hygiene, as documented on the resident’s MDS. During observed incontinence care, the CNAs did not disinfect the bedside table before placing clean, dry washcloths on it. One CNA then used both gloved hands to provide front perineal care and repeatedly used the same contaminated gloved hands to obtain and wring out a washcloth from a basin of warm water, thereby contaminating the wash water each time. After completing the initial front incontinence care, the resident was assisted to the left side and verbalized that urination was occurring again. As the resident urinated, the CNA used the already contaminated incontinence brief to catch the urine and did not provide additional front perineal care afterward. The CNA then used the same contaminated gloves to remove the urine-saturated brief and place a new brief without removing gloves, performing hand hygiene, or donning clean gloves. Barrier cream was not applied at the end of incontinence care. The CNA later acknowledged that incontinence care should have been repeated after the resident urinated again and that gloves and wash water had been contaminated during the process.
Failure to Provide Hot, Palatable Meals to Residents Receiving Room Trays
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide hot, palatable meals at safe and appetizing temperatures to residents receiving room trays, despite having a Food Temperatures Policy requiring hot foods to be held at 135°F or above and reheated to 165°F for at least 15 seconds. A test tray served on 12/30/25 at 12:50 PM contained a fish fillet, vegetables, pasta, bread, and peach cobbler; the internal temperature of the fish fillet was measured at 130°F and felt cold to the touch. The facility’s grievance log from 9/25/25 to 12/1/25 documented two grievances related to cold food during that period. The Dietary Manager acknowledged awareness of resident concerns about cold food from a resident council meeting about a month prior and stated that hot pucks were used for breakfast and lunch but not for supper, and that shoestring fries cooled rapidly after cooking and temperature checks. Multiple cognitively intact residents reported that food delivered to their rooms was frequently or consistently cold. One resident who eats in her room stated that the food is cold every time and that the heaters under the trays do not work. Another resident described the food as gross and often cold, citing a recent meal where the hamburger was served with fries that were ice cold. Additional residents reported that the food was so-so and often cold, that their only complaint was that room-delivered meals were always cold, and that the food was often cold and very institutionalized. Several CNAs corroborated these concerns, stating that residents receiving room or hall trays often complained that their food was cold, attributing this in part to dietary staff not placing heating pucks under plates and to delays in delivering meals to residents who do not eat in the dining room.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents' rights to be free from physical abuse, as evidenced by multiple incidents involving four residents. One resident with severe cognitive impairment and diagnoses including Major Depressive Disorder, Anxiety Disorder, Alzheimer's Disease, and Dementia with Psychotic Disturbance, struck another severely cognitively impaired resident with an open hand on the cheek during an altercation in a hallway. Staff observed the incident and intervened, but the altercation resulted in distress for both residents involved. Documentation shows that both residents had significant cognitive impairments, and the incident was reported to the state agency. In another series of incidents, a cognitively intact resident with Parkinson's Disease, Atherosclerosis, Prostate Cancer, and Aphasia pushed and kicked a severely cognitively impaired resident with Dementia, Psychosis, and Depression after being touched by her in the dining room. Multiple residents and staff reported that the cognitively impaired resident frequently touched others, which was unwelcome and led to physical responses from other residents, including being punched and kicked. Staff and residents acknowledged ongoing issues with this behavior, and staff interviews confirmed awareness of the situation, but the touching and resulting altercations continued to occur.
Failure to Provide Effective Dementia Care and Staff Training
Penalty
Summary
The facility failed to provide effective dementia treatment and services for a resident diagnosed with dementia, psychosis, and depression. The resident was noted to be severely cognitively impaired and exhibited behaviors such as touching other residents, which led to altercations. Multiple staff members, including registered nurses and certified nursing assistants, observed and reported the resident's behavior of touching others, and other residents expressed discomfort and frustration with these actions. Despite these ongoing behaviors, the resident's care plan did not document the behaviors or include interventions to address them, and behavior tracking records did not reflect any incidents. Interviews with staff revealed that they did not recognize the resident's touching as a behavioral issue, and several staff members, including CNAs, a dietary aide, and an LPN, reported not having received dementia training at the facility. The facility did not have a dementia unit or a dementia coordinator, and the administrator acknowledged the need for more dementia training, including early intervention and behavior management. These findings indicate a lack of appropriate assessment, care planning, and staff training related to dementia care for the resident in question.
Failure to Report Suspected Abuse and Sexual Assault to Law Enforcement
Penalty
Summary
The facility failed to recognize and report reasonable suspicion of a crime to law enforcement in three separate incidents involving allegations of physical and sexual abuse. In the first incident, a licensed practical nurse witnessed one resident striking another in the face, leaving a visible red mark. In a second incident, a resident was observed by another resident to have been struck on the upper arm by a different resident, with an audible 'pop' heard at the time. In both cases, the facility completed internal incident reports and notified the Illinois Department of Public Health (IDPH), but did not notify local law enforcement as required. A third incident involved an allegation of sexual assault against a resident by a visitor. The facility documented the allegation and reported it to IDPH, but again failed to notify law enforcement. The administrator/abuse prevention coordinator stated that they were unaware of the requirement to report such allegations to the police, believing that reporting to IDPH and completing an internal investigation was sufficient. Facility policies reviewed during the investigation clearly outlined the requirement to report reasonable suspicion of a crime to both the state survey agency and local law enforcement, including incidents of physical and sexual abuse.
Failure to Protect Cognitively Impaired Resident from Peer Abuse
Penalty
Summary
The facility failed to protect a severely cognitively impaired resident from physical abuse by two other residents. One incident involved a resident with no cognitive impairment who, after becoming frustrated and angry due to unsuccessful attempts to contact family, physically struck the cognitively impaired resident in the face. This act was witnessed by staff, who observed the aggressor approach the victim, raise a fist, and hit her on the cheek, resulting in visible redness and distress. The victim was assessed for injuries and was found to be upset and nervous following the incident. A second incident occurred in the dining room, where the same cognitively impaired resident was struck on the arm by another resident with no cognitive impairment. This event was reported by another resident, who witnessed the aggressor push the victim's wheelchair forcefully and then strike her on the arm after she attempted to greet him. The aggressor admitted to 'batting at' the victim and acknowledged having to swat at her to get her to leave him alone. Staff were not present in the dining room at the time of this altercation, and the incident was only reported after a resident sought out staff following the event. Both incidents highlight a lack of adequate supervision and monitoring, particularly during times when staff were occupied with other duties, such as meal service. The facility's own policy requires staff to monitor for behaviors that may provoke reactions and to review resident-to-resident altercations as potential abuse situations. Despite this, the cognitively impaired resident was subjected to repeated physical aggression by peers, with staff either not present or unable to intervene in time to prevent harm.
Failure to Remove Aggressive Resident from Room with Vulnerable Roommate After Abuse Incident
Penalty
Summary
The facility failed to remove a resident, identified as the perpetrator of physical abuse, from direct access to his vulnerable, dependent, and non-verbal roommate after an incident of physical aggression. The resident who committed the abuse was assessed as having no cognitive impairment, while his roommate was documented as having severe cognitive impairment, being totally dependent on staff for all activities of daily living, and unable to ambulate. After the aggressive resident physically struck another resident, leaving a visible injury, staff expressed concern for the safety of his non-verbal roommate, who could not defend himself or communicate effectively. Despite these concerns, the administrator and abuse prevention coordinator directed staff not to move the aggressive resident or his vulnerable roommate to different rooms. Staff, including an LPN and a CNA, reported their worries about the roommate's safety and monitored the situation closely, but the two residents remained in the same room overnight following the incident. The facility's own policy requires immediate steps to protect residents from further abuse once abuse has been identified, but this was not followed in this case.
Failure to Maintain Complete and Accurate Medical Records Following Abuse Incidents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents involved in incidents of physical abuse. In one case, a resident became physically aggressive with another resident, resulting in a red mark on the victim's right upper cheek. The nursing progress notes did not include documentation of the physical abuse, measurements of the injury, or notifications to family or physician. Additionally, there was no ongoing assessment or monitoring of the resident's response to the incident, and required 72-hour follow-up documentation was not initiated. In a separate incident, another resident was reported to have struck the same victim on the arm in the dining room. The medical records for both the alleged perpetrator and the victim did not contain documentation of the physical abuse, notifications to family or physician, or any ongoing assessment or monitoring following the event. The facility's own policy requires documentation of assessment, notifications, interventions, and evaluation, including 72-hour alert charting after incidents or changes in condition, which was not followed in these cases. Interviews with nursing staff and administration confirmed that documentation was incomplete and did not meet facility policy expectations. The staff acknowledged the lack of injury measurement, absence of abuse documentation in the medical records, and failure to document required notifications and follow-up assessments. The deficiency was identified through review of progress notes, incident reports, and staff interviews, which revealed gaps in recordkeeping and failure to adhere to established documentation protocols.
Failure to Timely Report Alleged Abuse
Penalty
Summary
Facility staff failed to immediately report an allegation of staff-to-resident physical and verbal abuse to the facility administrator, affecting one resident. The facility's abuse prevention policy mandates reporting all allegations of abuse within required timeframes according to Federal and State statutes. The Code of Federal Regulations requires that all alleged violations involving abuse be reported immediately, or not later than 2 hours if serious bodily injury is involved, or within 24 hours if not. However, the incident report and subsequent investigation revealed that a cook (V4) observed another cook (V3) allegedly abusing a resident (R1) on the evening of 8/7/2024. V4 reported the incident to their manager (V6) during suppertime, but V6 did not inform the facility administrator (V1) until the following morning. Interviews conducted on 8/20/2024 and 8/21/2024 confirmed the delay in reporting. V4 reported the abuse allegation to V6 between 6-6:30 PM on 8/7/2024, requesting V6 to inform V1. V6 acknowledged receiving the report but did not take immediate action, stating they were leaving work for the day. Another cook (V5) corroborated V4's account, observing the report to V6 and hearing V6's assurance to contact V1 as soon as possible. V6 admitted to not informing V1 until the next day and did not make any observations or inquiries regarding the alleged perpetrator or victim after receiving the report. This inaction resulted in a failure to comply with the required reporting timeframes for abuse allegations.
Failure to Identify Root Cause of Pain
Penalty
Summary
The facility failed to identify the root cause of pain for a resident who had multiple diagnoses, including a fractured neck of the right femur with open reduction and internal fixation, right hip pain, dementia, and osteoarthritis. The resident was admitted to the facility from a local hospital and was noted to be in severe pain. Initial pain management with Tylenol was ineffective, and the resident continued to experience severe pain, which was later managed with narcotic pain medication. Despite this, the facility did not assess the root cause of the increasing pain following the resident's fall or attempt other interventions to identify the cause of the pain. The resident's care plan and progress notes documented severe pain and cognitive impairment, with indicators of pain such as nonverbal sounds, vocal complaints, facial expressions, and protective body movements. The resident fell while trying to get out of bed, and although no immediate injuries were noted, the resident continued to experience severe pain. The facility's pain management policy required a comprehensive pain assessment upon admission, transfer, or onset of new pain, but there was no documentation that such an assessment was conducted to identify the root cause of the resident's pain. The resident's family member reported that the resident was in a lot of pain during the entire stay at the facility and had a large bump on the right hip upon discharge. The orthopedic surgeon confirmed that the resident had broken the entire head off the femur bone and required a total hip replacement. The facility's failure to investigate the cause of the resident's pain and provide appropriate interventions resulted in the resident experiencing continued severe pain and requiring narcotic pain medications.
Unqualified Dietary Manager and Sanitation Issues
Penalty
Summary
The facility failed to employ a clinically qualified Director of Food and Nutrition Services, which has the potential to affect all 53 residents in the facility. On 4/9/2024, the Dietary Manager (V8) was observed supervising dietary operations and reported being the full-time manager of the facility food service. However, V8 admitted to not being a clinically qualified Certified Dietary Manager or having equivalent training, and did not meet the State of Illinois standards to be a food service manager or dietary manager. V8 also confirmed that the facility dietician does not work full-time in the facility. Additionally, on 4/9/2024, the facility dietary staff failed to prevent direct cross-contamination of food and did not maintain sanitary food storage areas. V8 reported that the food prepared in the facility kitchen is available for all residents to eat. The facility's Long-Term Care Facility Application for Medicare and Medicaid, dated 3/9/2024, documents that 53 residents reside in the facility.
Failure to Maintain Sanitary Food Storage Areas
Penalty
Summary
The facility failed to prevent direct cross-contamination of stored food and maintain sanitary food storage areas. On 4/9/2024 at 11:05 AM, three wire shelving sections in the kitchen walk-in cooler were observed to be partially covered with a gray-colored, fuzzy biological growth resembling mold. Boxes of food items, pans of prepared food, and jugs of milk were stored directly on these contaminated shelving racks. Additionally, on 4/9/2024 at 11:21 AM, the walk-in freezer's evaporator/condenser supply lines were leaking accumulated condensation onto boxes of food stored below on shelving. The leak had dripped directly into a fully open box of frozen green beans, partially covering the product. The Dietary Manager confirmed the presence of condensation on the green beans. The facility's Long-Term Care Facility Application for Medicare and Medicaid documented that 53 residents resided in the facility at the time of the survey.
Failure to Ensure Dignified Activities of Daily Living
Penalty
Summary
The facility failed to ensure residents' rights to dignified activities of daily living, affecting six residents. On multiple occasions, residents in the dining room were observed waiting for meals for extended periods, with some waiting up to fifty minutes after others had been served. This issue was corroborated by resident council meeting minutes and resident interviews, indicating that meals were consistently served late, causing distress and dissatisfaction among the residents. Another deficiency involved a resident who required extensive assistance for toileting due to limited mobility and cognitive impairment. The resident and her roommate reported long wait times for assistance, sometimes up to an hour and a half, leading to incontinence episodes. Staff interviews confirmed the resident's history of moisture-associated skin damage and urinary tract infections, and acknowledged the delays in responding to call lights, which compromised the resident's dignity and comfort. Additionally, a resident with severe cognitive impairment and multiple medical diagnoses was repeatedly observed in soiled clothing over several days. Despite the availability of clothing protectors and staff's responsibility to assist with hygiene, the resident remained in dirty clothes, which was confirmed by the resident's power of attorney and the Director of Nurses. This failure to maintain the resident's dignity and hygiene was evident through multiple observations and staff interviews.
Inadequate Supervision and Documentation of Falls
Penalty
Summary
The facility failed to adequately supervise a resident (R40) at risk for self-harm and did not document a resident (R159) fall into the facility's risk management system, initiate neurological checks, conduct a fall investigation, determine a root cause, and implement a specific fall intervention to aid in future fall prevention. R40, who has severe cognitive impairment and uses a wheelchair for mobility, exhibited behaviors such as eating non-food items, taking items that are not his, and becoming verbally and physically aggressive. Despite multiple incidents where R40 ingested or attempted to ingest hazardous substances like hand sanitizer and medicated cream, the facility did not provide constant supervision, especially on weekends when ancillary staff were not present. Staff and physicians acknowledged the need for diligent supervision, but lapses continued to occur, leading to repeated incidents of self-harm risk for R40. R159, diagnosed with repeated falls, psychotic disorder, mild cognitive impairment, dementia, motor and sensory neuropathy, and muscle weakness, experienced an unwitnessed fall while attempting to self-transfer to his wheelchair. The fall was not documented in the risk management system, and no neurological checks were initiated. Additionally, a fall investigation was not conducted, a root cause was not determined, and no new fall interventions were implemented. This lack of documentation and follow-up led to another fall for R159 within a week. The facility's failure to supervise R40 adequately and to document and investigate R159's fall demonstrates significant lapses in ensuring resident safety and preventing accidents. These deficiencies affected two of the five residents reviewed for accidents and supervision, highlighting the need for improved monitoring and documentation practices to prevent future incidents.
Failure to Serve Meals at Appetizing Temperature
Penalty
Summary
The facility failed to provide residents with food at an appetizing temperature, affecting four residents who were cognitively intact. During a resident group meeting, the residents reported that their meals were often served up to one and a half hours late, resulting in hot food being served cold. The Dietary Manager (DM) confirmed that the food comes out of the kitchen at safe hot temperatures but sits on the hall for 30 to 45 minutes before being delivered by the Certified Nursing Assistants (CNAs). The DM also observed food sitting in the dining room for 30 minutes before being served, leading to complaints from residents about the temperature of their meals. The issue was documented in the facility's Resident Council meeting notes for three consecutive months, indicating ongoing concerns about meal temperatures. The DM stated that the kitchen is willing to reheat the food if notified, but the CNAs need to communicate this. The problem persisted despite the DM discussing it with the nursing staff, highlighting a breakdown in the process of delivering meals promptly to residents. The residents confirmed that no cold food had been served since the state surveyors arrived, suggesting temporary improvements during the survey period.
Failure to Provide Bedtime Snacks
Penalty
Summary
The facility failed to provide bedtime snacks for four residents (R11, R12, R18, and R31) who were reviewed for bedtime snacks. These residents, who have no cognitive impairment, reported during a resident group meeting that snacks are not stocked daily or offered at bedtime. Additionally, the snack cart is sometimes placed in the linen room instead of the nurses' station, making it inaccessible to residents. Two of the residents, who have Diabetes Mellitus, expressed the need for snacks to manage their blood sugar levels. The Dietary Manager was unaware of any issues with snack availability, while the Assistant Director of Nursing and Director of Nursing were not aware that snacks were not being provided at bedtime. The ADON mentioned that the snack cart is placed in the linen room to prevent a wandering diabetic resident from consuming inappropriate snacks.
Failure to Follow Up on Lab Results and Improper Medication Administration
Penalty
Summary
The facility failed to follow up with the physician regarding laboratory results for a resident with severe cognitive impairment and multiple diagnoses, including unspecified dementia and anxiety. The resident's lab results, which were abnormal, were faxed to the physician, but the necessary follow-up did not occur until 19 days later, after the surveyor inquired about the labs. This delay prevented the timely adjustment of the resident's medication, specifically the increase of Ferrous Sulfate to address low iron levels. Additionally, the facility allowed unlicensed personnel to administer medication. A Certified Nurse Aide (CNA) applied Zinc Oxide paste to a resident's perineal area after completing urinary catheter care, which is against the facility's standard of care. The Director of Nursing confirmed that only licensed nurses are permitted to apply medicated creams, and the CNA was unaware of this protocol. This incident highlights a lapse in staff training and adherence to medication administration policies.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident (R15), who has moderate cognitive impairment and requires extensive assistance for toileting due to limited range of motion and other health issues. Despite having a care plan that mandates peri-care anytime R15 is toileted and as needed, staff often delayed responding to R15's call light, sometimes taking up to an hour or more. This delay led to R15 experiencing incontinence episodes and sitting in wet incontinence briefs, causing discomfort and skin irritation. R15's roommate and other staff confirmed these delays, noting that R15 often had to wait long periods for assistance, which compromised her dignity and comfort. R15's medical history includes taking Furosemide, which increases urine production, and a history of urinary tract infections (UTIs) and Moisture Associated Skin Damage (MASD). Staff interviews revealed that R15 frequently experienced redness and soreness in her peri-area due to prolonged exposure to wet briefs. Although staff applied barrier creams to manage skin irritation, the delays in providing timely incontinence care persisted. The Assistant Director of Nursing acknowledged the issue, stating that call lights should be answered within five minutes and bathroom call lights within a minute, but this standard was not consistently met for R15.
Failure to Follow Pressure Ulcer Treatment and Repositioning Interventions
Penalty
Summary
The facility failed to follow a physician-ordered pressure ulcer treatment and implement pressure ulcer interventions for a resident with multiple Stage 4 pressure ulcers. The resident, who has medical diagnoses including paraplegia and muscle weakness, was observed multiple times laying on his back in a reclined wheelchair, despite care plan interventions requiring repositioning every two hours and only being on his back while eating. The resident expressed discomfort and pain from being in the wheelchair for extended periods, indicating that the repositioning interventions were not being followed by the staff. Additionally, during a dressing change, an LPN did not cleanse the resident's Left Ischium pressure ulcer before applying a new dressing and used the wrong type of dressing on the Right Ischium pressure ulcer. The LPN admitted to not reviewing the physician orders prior to the dressing change and acknowledged the mistake. The Director of Nurses confirmed that the physician orders were not followed and that the facility did not have a specific policy for clean dressing changes, relying instead on standard nursing education and practice.
Failure to Check PEG Tube Placement Before Medication and Feeding Administration
Penalty
Summary
The facility failed to check the placement of a Percutaneous Endoscopic Gastrostomy (PEG) tube prior to the administration of medication and enteral feeding for one resident. The resident, who has severe cognitive impairment and multiple medical diagnoses including Hemiplegia, Hemiparesis, and Cerebrovascular Disease, had a physician's order to check the PEG tube placement and residual volume before administering medications and feedings. However, during an observation, a Registered Nurse (RN) administered medications and resumed enteral feeding without performing the required checks for tube placement and residual volume. The RN admitted to not following the facility's policy, which mandates checking the PEG tube placement and residual volume before each medication administration and feeding. The Director of Nurses (DON) confirmed that the nursing staff should always check the placement of the PEG tube to ensure that medications, water, and feeding are administered correctly. The facility's policy on tube feeding outlines specific steps for verifying tube placement and checking residual gastric contents, which were not followed in this instance.
Failure to Maintain Respiratory Equipment
Penalty
Summary
The facility failed to provide, change, date, and maintain respiratory equipment according to physician orders and facility policy, affecting three residents. For Resident 8, the oxygen tubing and nasal cannula were not dated, and there was no humidifier bottle attached to the oxygen concentrator, despite physician orders and facility policy requiring these actions. The family member and an LPN confirmed the lack of proper equipment maintenance. Resident 8 was on hospice care, and the hospice was supposed to provide the necessary supplies, which were not present at the time of observation. For Resident 22, the oxygen concentrator was dispensing oxygen at 2 liters per minute, but the nasal cannula tubing and humidifier water bottle were not dated to indicate when they were last changed. An LPN confirmed that the equipment should have been changed. Resident 31's oxygen tubing and humidifier bottle were outdated and not changed according to the schedule. The humidifier bottle was empty, and the resident was unaware of the maintenance schedule. An LPN confirmed the outdated equipment and the empty humidifier bottle. The facility policy requires weekly changes and proper dating of respiratory equipment, which was not followed in these cases.
Failure to Provide Mail Service on Saturdays
Penalty
Summary
The facility failed to provide mail service to residents on Saturdays, affecting all 53 residents. During a resident group meeting, multiple residents confirmed that no mail is delivered to them on Saturdays. The Activity Director stated that while mail is delivered by the post office on Saturdays, it remains locked up and inaccessible to staff until Monday. The Human Resource Director/Front Desk Receptionist corroborated this, explaining that mail is sorted and given to Activity staff during the week, but not on Saturdays due to the absence of staff to sort it. Consequently, residents do not receive their mail until the following Monday.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, homelike environment for two residents, R5 and R7. R5's room and bathroom were observed to be in poor condition, with a recliner chair obstructing the bathroom door, scuffed walls, and feces splattered on the walls and floor. Despite the resident's complaints and the Director of Nurses' acknowledgment of the issue, the bathroom remained unclean the following day. R5 expressed frustration over the unsanitary conditions and the lack of timely cleaning by the facility staff. R7's bathroom was also found to be in an unacceptable state, with damp bath blankets piled in the corner, a strong musty odor, and a broken toilet. The resident had to use a toilet in a different location due to the malfunctioning toilet in her room. Despite the bathroom being out of commission, R7 continued to use it for handwashing, which the Director of Nurses was unaware of. The resident and a Certified Nurse Aide both expressed concerns about the cleanliness and odor of the bathroom. The Resident Council Minutes documented ongoing complaints about soiled incontinence briefs being left in trash cans, which were not adequately addressed despite multiple reports to the Director of Nurses. The facility's failure to maintain a clean and homelike environment for these residents highlights significant deficiencies in housekeeping and maintenance practices, impacting the residents' quality of life and comfort.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency for one resident out of three reviewed for skin alterations. The resident, who has severe cognitive impairment and multiple medical diagnoses including Alzheimer's Disease and a history of traumatic brain injury, was found with bruises on the right mid-back and right lower back. These bruises were discovered by a registered nurse in the shower room and were described as dark purple and square-shaped. The resident could not explain how the bruises occurred, and no staff witnessed the incident. The facility's Director of Nurses and Administrator discussed the bruises but did not report them to the State Agency, despite acknowledging that the bruises were in an unusual location and could not rule out abuse. The facility's policy requires that injuries of unknown origin be reported as potential crimes under State and Federal Law. However, the Director of Nurses and the Administrator did not report the bruises, believing that reporting was only necessary if the injuries required treatment outside the facility. The facility's failure to report the bruises was a violation of their own policy and regulatory requirements. The Director of Nurses admitted that the facility could not determine the exact cause of the bruises and should have reported them to the State Agency.
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.
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What surveyors actually found near you
We read the 110 citations issued within 25 miles in the last 12 months — including the 4 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.
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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.
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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) |
|---|---|---|---|---|
| Providence Health Care Center | 14.7 mi | — | 1 | 0 |
| Westridge Health Care Center | 15.4 mi | — | 10 | 0 |
| Twin Lakes Extended Care | 15.4 mi | — | 1 | 0 |
| Springhill Village | 16.1 mi | — | 5 | 0 |
| The Haven Of Paris | 16.2 mi | — | 30 | 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 August 2026) and official state health department websites.