Marshfield Care Center: CPR Response Failures - MO
The incident unfolded around 5 a.m. when an aide alerted LPN A that a resident was unresponsive. The nurse entered the room but left almost immediately to hunt for the resident's code status at the nurses' station.
"He/she looked in the resident's physician orders, face sheet, and the code status book, and was unable to retrieve the resident's code status," according to the inspection report.
After five minutes of searching and calling EMS, the nurse returned to begin CPR with other staff members. EMS arrived around 5:30 a.m. and continued resuscitation efforts before transporting the resident to the hospital.
The facility's own staff knew the system was broken. LPN D told inspectors he "had heard there was a delay in a code being started for the resident, due to the status not being found." When inspectors checked the Code Status Book, the resident's information wasn't there.
Multiple staff members described where code statuses should appear: on residents' charts, face sheets, physician orders, care plans, door name tags, and in the code status book at the nurses' station. Blue name tags meant full code. White meant no CPR.
Nobody was maintaining the system. The Social Services Director, responsible for updating code statuses across all locations, told inspectors the position had been vacant "for some time" and updates "hasn't been getting done."
A newly hired Social Services Director was "working on doing audits on all resident's code status as there is some discrepancies" but had only been employed for a couple weeks.
The Medical Director expected code statuses to "be able to be found in a quick manner for efficiency."
Instead, a resident's life hung in the balance while a nurse rifled through paperwork.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Marshfield Care Center For Rehab and Healthcare from 2025-11-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
MARSHFIELD CARE CENTER FOR REHAB AND HEALTHCARE in MARSHFIELD, MO was cited for violations during a health inspection on November 21, 2025.
The incident unfolded around 5 a.m.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.