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 Presidential Post-acute during CMS and state inspections, most recent first.
A resident with multiple cardiac and neurological diagnoses had a physician order for metoprolol succinate ER 25 mg to be given once daily with instructions that it may be split but not crushed. During a medication pass, an LPN placed several medications, including the metoprolol succinate ER, into a cup and then into a crush pouch and crushed them before administration. In a later interview, the LPN confirmed she had crushed the extended-release metoprolol and acknowledged it should not have been crushed. Facility policy required medications to be administered in accordance with prescriber orders.
A resident with type 2 DM and intact cognition had a physician order for Insulin Lispro 23 units SQ before meals, with instructions to hold the dose if blood sugar was below 150. Review of the MAR and blood sugar records showed that nursing staff administered insulin on several occasions when the resident’s blood sugar was under 150, without any documented physician notification or new orders authorizing administration outside the parameters. An LPN confirmed that insulin was given contrary to the order and that it should have been held unless otherwise directed. Facility policy required medications to be given per prescriber orders and for the physician or medical director to be contacted if a dosage was believed inappropriate, but this was not followed.
A resident with significant mobility limitations and a care plan requiring two-person assistance for transfers sustained a rib fracture after being transferred by only one staff member, who also failed to follow proper transfer technique. Additional incidents showed continued noncompliance with care plan requirements, including failure to lock wheelchair brakes and lack of proper staff assistance, leading to actual harm.
Nursing staff did not follow physician orders or facility policy for enhanced barrier precautions during wound care for a resident with multiple comorbidities and wounds. During a wound care procedure, two nurses failed to wear gowns as required, despite the resident's care plan and orders specifying the use of PPE, including gowns and gloves, for high-contact care activities.
A facility failed to use appropriate needles for intramuscular injections, as observed when an RN attempted to administer an antibiotic to a resident using a blunt fill needle-filter. The RN was unaware of the correct needle type, and the Director of Nursing confirmed the error, stating that a 19-23 gauge, 1.0 to 1.5-inch needle should be used. The facility's policy and manufacturer's guidance also indicated the blunt fill needle should not be used for skin injections.
A resident with multiple health conditions experienced significant weight loss, which the facility failed to address in a timely manner. Despite the care plan's interventions and the RD's recommendations, the facility did not document a re-weight or follow up on the weight loss until over two weeks later, contrary to their policy.
The facility failed to properly store chemicals in the kitchen, leading to a potential risk of cross-contamination for 74 of 76 residents. Observations revealed comet bleach powder and dawn dish detergent stored on the kitchen preparation sink, which is used for food preparation. Staff confirmed the improper storage and the facility's policy requiring chemicals to be stored separately.
A resident with severe cognitive impairment and multiple diagnoses was observed twice with their urinary catheter drainage bag lying uncovered on the floor. An STNA confirmed this was against facility policy, which mandates that catheter tubing and drainage bags be kept off the floor for infection control.
The facility failed to maintain a replacement tracheostomy tube at the bedside for a resident requiring tracheostomy care. The resident, with a history of severe medical conditions including brain injury and respiratory failure, was observed without the necessary replacement tube in her room, contrary to the facility's policy.
Improper Crushing of Extended-Release Medication
Penalty
Summary
The facility failed to ensure medications were administered according to prescriber orders when a nurse inappropriately crushed an extended-release medication for a resident. The resident, admitted with diagnoses including acute embolism and thrombosis of the left axillary vein, dementia, atrial fibrillation, and hypertensive heart disease with heart failure, had a physician order for metoprolol succinate ER 25 mg by mouth once daily with instructions that the tablet may be split but not crushed. During a medication pass observed at 8:40 A.M., an LPN placed multiple medications for this resident, including amiodarone 200 mg, escitalopram 10 mg, metoprolol succinate ER 25 mg, pantoprazole 40 mg, furosemide 20 mg, and spironolactone 25 mg, into a medication cup, then into a crush pouch, and crushed them. In a subsequent interview, the LPN confirmed that she had crushed the metoprolol succinate ER and acknowledged it should not have been crushed because it was an extended-release tablet, and stated she did not crush the pantoprazole. Review of the facility’s “Administering Medications” policy dated April 2019 showed that medications are to be administered in accordance with prescriber orders, including required time frames. This issue was identified during an investigation under Complaint Number 2707817.
Insulin Administered Outside Ordered Blood Glucose Parameters
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order for insulin administration, resulting in significant medication errors for one resident with type 2 diabetes. The resident was readmitted on 03/03/26 and had an entry MDS BIMS score of 15, indicating intact cognition. A physician’s order dated 03/03/26 directed that Insulin Lispro 23 units be administered subcutaneously before meals, with explicit instructions to hold the insulin if the resident’s blood sugar (BS) was less than 150. Review of the resident’s Medication Administration Record (MAR) and blood sugar summary showed that insulin was administered on multiple occasions when the BS was below the ordered parameter: on 03/05/26 at 11:30 A.M. for a BS of 107, on 03/06/26 at 6:30 A.M. for a BS of 127, on 03/06/26 at 4:30 P.M. for a BS of 97, and on 03/07/26 at 6:30 A.M. for a BS of 114. Further review of the resident’s progress notes revealed no documentation that the physician had been notified or had provided any new order authorizing insulin administration outside the specified BS parameters. During an interview on 03/11/26 at 9:47 A.M., LPN #180 confirmed that insulin had been given when the resident’s BS was below 150 and acknowledged that the insulin should have been held unless the physician ordered otherwise, which would have been documented in the progress notes. Review of the facility’s “Administering Medications” policy, revised April 2019, showed that medications are to be administered in accordance with prescriber orders and that the physician or medical director should be contacted if a dosage is believed to be inappropriate or excessive. The facility’s failure to adhere to the physician’s insulin order and its own medication administration policy resulted in the cited deficiency, investigated under Complaint Number 2707817.
Failure to Provide Required Assistance During Resident Transfers Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident, who was at risk for falls due to functional decline, weakness, and bedbound status, did not receive the required assistance from two staff members during transfers as specified in her care plan. The resident's care plan, updated shortly after admission, clearly indicated the need for two-person assistance during transfers and for staff to lock wheelchair brakes. Despite these interventions, the resident reported pain after a transfer, and subsequent X-rays confirmed a new acute nondisplaced left tenth rib fracture. The resident stated that the aide performing the transfer squeezed too tightly and that only one staff member was present during the transfer, contrary to the care plan requirements. Further review of the resident's medical record and interviews revealed that the resident continued to be dependent on staff for transfers and had intact cognition. Additional incidents were noted, including an event where the resident had to be lowered to the floor during a transfer because a wheelchair brake was not locked, again with only one staff member present. Staff interviews and documentation confirmed that the required two-person assistance was not consistently provided, and there was a lack of written documentation or retraining for staff involved in these incidents. Radiological evidence confirmed that the rib fracture was a new injury, not related to any prior incident before admission. The facility's investigation was unable to identify the specific staff member responsible for the July transfer that resulted in the fracture. The facility's policy required that residents unable to perform activities of daily living independently receive necessary services and assistance in accordance with their care plan, which was not followed in these instances.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) as ordered by the physician during wound care for a resident with multiple comorbidities, including congestive heart failure, chronic kidney disease, diabetes mellitus, and morbid obesity. The resident required assistance with activities of daily living and had wounds that necessitated EBP during high-contact care activities. The care plan and physician orders specified the use of personal protective equipment (PPE), including gowns and gloves, during high-contact care such as wound care. During an observed wound care procedure, two nurses provided care to the resident's sacrum/right buttocks without wearing gowns, contrary to both the physician's orders and the facility's EBP policy. The nurses confirmed in interviews that a gown should have been worn during the procedure. Review of the facility's policy and CDC guidance further supported the requirement for gown and glove use during high-contact care for residents with wounds. This deficiency was identified during a complaint investigation and affected one of three residents reviewed for wounds.
Improper Needle Use for Intramuscular Injection
Penalty
Summary
The facility failed to ensure the appropriate needles were used during intramuscular medication administration for a resident. During an observation of medication administration, a registered nurse (RN) was preparing to administer an antibiotic to a resident diagnosed with a urinary tract infection and moderate protein-calorie malnutrition. The RN initially used a BD blunt fill needle-filter to draw up the lidocaine solution and mix it with the Ertapenem sodium injection powder. After mixing, the RN attempted to use another blunt fill needle-filter to administer the medication intramuscularly, which was inappropriate for this type of injection. The surveyor intervened before the medication was administered, and the RN confirmed the use of a blunt fill needle-filter for injections, indicating a lack of knowledge about the correct needle type for intramuscular injections. The Director of Nursing confirmed that a blunt fill needle-filter should not be used for skin injections and that a 19-23 gauge, 1.0 to 1.5-inch needle should be used instead. The facility's policy and the manufacturer's guidance for the BD blunt fill needle also indicated that it should not be used for skin injections, highlighting the deficiency in following proper procedures for medication administration.
Failure to Address Resident's Significant Weight Loss
Penalty
Summary
The facility failed to timely address and follow through with recommendations for a resident's significant weight loss. Resident #100, who had diagnoses including metabolic encephalopathy, Alzheimer's disease, dementia, dysphasia, chronic obstructive pulmonary disease, and mild protein calorie malnutrition, experienced a weight loss of 9.8% in one month and 8.9% in one week upon readmission to the facility. The resident's care plan included interventions such as providing adequate time for meal consumption, assisting with meals and fluids, and monitoring meal intake and weight. Despite these interventions, the facility did not document a re-weight as recommended by the Registered Dietitian (RD) on 09/12/24, nor did they follow up on the significant weight loss identified on 09/30/24 until over two weeks later. The RD, who was present at the facility twice weekly, confirmed the lack of evidence for a re-weight and follow-up after the significant weight loss. The facility's policy required that any weight change of 5% or more since the last assessment should be retaken the next day for confirmation and the RD notified immediately. However, the facility did not adhere to this policy, resulting in a delay in addressing the resident's nutritional needs. The Administrator acknowledged that any issues of weight loss should be followed up with immediately, but the facility failed to do so in this case.
Improper Chemical Storage in Kitchen
Penalty
Summary
The facility failed to properly store chemicals in the kitchen, leading to a potential risk of cross-contamination for 74 of 76 residents who received food from the kitchen. During an observation, comet bleach powder and dawn dish detergent were found stored on the kitchen preparation sink, which is used for food preparation activities such as dicing peppers, onions, slicing tomatoes, and cleaning lettuce. Cook #293 confirmed the presence of these chemicals on the sink but was unaware of why they were there. A subsequent observation revealed dawn dish detergent stored on the kitchen preparation sink again. The Dietary Director confirmed that kitchen chemicals should be stored in the chemical supply closet, as per the facility's Chemical Storage Policy dated March 2019, which mandates that chemicals must be stored in a designated area separate from food preparation, storage, and serving areas to prevent contamination.
Improper Positioning of Urinary Catheter Drainage Bag
Penalty
Summary
The facility failed to maintain the proper position of a urinary catheter drainage bag for a resident. The resident, who was admitted with diagnoses including metabolic encephalopathy, retention of urine, dementia, benign neoplasm of the pituitary gland, obstructive reflux uropathy, and testicular hypofunction, was observed on two separate occasions with the urinary catheter drainage bag lying uncovered directly on the floor. The resident was severely cognitively impaired and required partial moderate assistance with toileting. An STNA verified that the drainage bag should not be on the floor, and the facility's policy confirmed that catheter tubing and drainage bags should be kept off the floor for infection control purposes.
Failure to Maintain Replacement Tracheostomy Tube at Bedside
Penalty
Summary
The facility failed to maintain a replacement tracheostomy tube at the bedside for a resident requiring tracheostomy care. Resident #7, who had a history of diffuse traumatic brain injury, quadriplegia, aphasia, hydrocephalus, and acute and chronic respiratory failure, was observed without a replacement tracheostomy tube in her room. This was confirmed by both the RN Manager and another RN. The facility's policy, dated October 2023, mandates that a replacement tracheostomy tube must be available at the bedside at all times, which was not adhered to in this instance.
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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 Marion
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marion Nursing & Rehab | 2.3 mi | — | 21 | 0 |
| Marion Pointe | 2.7 mi | — | 9 | 0 |
| Marion Valley Post Acute | 2.7 mi | — | 7 | 0 |
| Meadows Of Marion Health And Rehabilitation The | 3.1 mi | — | 2 | 0 |
| Harding Pointe | 3.1 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 August 2026) and official state health department websites.