Marshall Manor West

In the surveyor’s words

From the most serious findings on record at Marshall Manor West, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Oct 22, 2025

  Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as possible and provide supervision to prevent avoidable accidents for 1 of 3 residents reviewed for transfers. (Residents #1)The facility failed to keep Resident #1 free from injury after he was improperly transferred by CNA A on 10/19/25 causing extensive bruising to his chest and multiple rib fractures.This failure resulted in the identification of an Immediate Jeopardy (IJ) on 10/21/25 at 11:35 a.m. […]

• Actual harm, isolatedF690Feb 4, 2026

  Based on observation, interview, and record review the facility failed to provide the appropriate care and services to prevent urinary tract infections to the extent possible for 1 of 2 residents reviewed for indwelling catheters. (Resident #9) -Resident #9 had a urinalysis specimen obtained on 01/30/26 due to complaint of discomfort from lower abdomen to his penis and cloudy urine. The facility staff did not follow up on obtaining results and Resident #9 continued with signs of a possible UTI. This failure could place residents at risk of not receiving the required level of care and possible sepsis. Findings included:Record review of a face sheet dated 02/04/26 indicated Resident #9 was a [AGE] year-old male admitted on [DATE]. […]

• No harm, potential for more than minimal, widespreadF812Feb 4, 2026

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation in that: The facility failed to ensure the fryer was clean and free of debris.The facility failed to ensure baking sheets did not have brown and black colored buildup and debris of particles on the outside.The facility did not ensure skillets did not have brown and black colored buildup on the inside and outside.The facility failed to ensure a pack of cigarettes, and a fly swatter was not stored under the cutting boards touching the oven mittens.The facility failed to maintain cleanliness of the floor in the kitchen prep area.The facility failed to ensure dietary… […]

• No harm, potential for more than minimal, widespreadF925Feb 4, 2026

  Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that facility was free of pests and rodents for 1 of 1 kitchen. The facility did not maintain an effective pest control program to ensure the facility was free of roaches in the kitchen. This failure could place residents at risk for an unsanitary environment and a decreased quality of life.The findings included: During an observation of the facility's kitchen on 02/02/2026 at 11:16 a.m., During lunch meal prep there was approximately one dime size light brown roach crawling from the stove area to where pan sheets were stored in the kitchen. During an observation on 02/03/2026 at 11:00 a.m. […]

• No harm, potential for more than minimal, widespreadF803Nov 6, 2024

  Based on observation, interview, and record review, the facility failed to ensure that the menu was followed for the lunch meal on 11/04/24 and 11/05/24 for 2 of 2 meals (the lunch service) reviewed for nutritional adequacy. The facility did not serve fried chicken, as planned, with the lunch meal on 10/04/2024 nor informed residents that a substitute would be used. The facility failed to serve Salisbury steak with the lunch meal on 10/05/2024 nor informed residents that a substitute would be used. These failures could affect all residents in the facility by placing them at risk of not receiving adequate nutritive food value needed to promote/maintain health. […]