Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
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 Manor West during CMS and state inspections, most recent first.
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.
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.
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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 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 | — | 0 | 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.