Marbridge Villa

Based on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. The facility failed to ensure CK A and DM were holding cold foods below the danger zone temperature of 41 degrees Fahrenheit and below. The facility failed to ensure CK A checked food temperatures and recorded temperatures correctly. The facility failed to ensure CK A and DM periodically monitored throughout the meal service to ensure proper cold holding temperatures are maintained for the macaroni salad. The facility failed to ensure functioning of reach in refrigerator and temperature at 41 degrees Fahrenheit and below. This failure could place residents who were served from the kitchen at risk for consuming contaminated food, and/or developing foodborne illnesses. Findings included: Observation on 05/28/2025 at 10:54 AM, revealed CK A preparing lunch and placing deep stainless steel steam table pans of food on the warming table and checking…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 8 residents (Resident #8, Resident #27, Resident #53, and Resident #57) reviewed for infection control. 1. During pericare, CNA J folded and reused a disposable wipe when cleaning the groin and penis for Resident #27. 2. MA G did not conduct hand hygiene after preparing medications and prior to administering the medications for Resident #53 and Resident #57. 3. LVN I failed to ensure supplies that were to be used on multiple residents was not placed on a dirty surface in a resident's room for Resident #8. These failures could place residents at risk of transmission of disease and infection. Findings included: 1. Record review of Resident #27's admission record, dated 05/29/2025, reflected a [AGE] year-old…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews the facility failed to ensure personal privacy for 2 of 3 residents (Resident #8 and Resident #56) reviewed for privacy while receiving care. 1. The facility failed to ensure the privacy of Resident #56 by not closing the door or pulling the privacy curtain during administration of enteral formula through a PEG tube. 2. The facility failed to ensure the privacy of Resident #8 by not closing the blinds on the window or pulling the privacy curtain during wound care. This failure could place residents at risk of loss of privacy and dignity. Findings included: 1. Record review of Resident #56's admission record, dated 05/29/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #56 had diagnoses which included: thrombocytopenia (a condition characterized by a low platelet count and may cause easy bruising and/or prolonged bleeding), aphasia (a language disorder that affects communication), dysphagia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 1 (D/E Hall) medication room reviewed for pharmacy services. The facility failed to ensure expired medication and medical supplies were removed from D/E-halls medication storage room. This failure could place residents at risk of receiving an expired medication, not reaching the intended therapeutic dose, inaccurate results, and/or contamination from expired supplies. Findings included: During an observation on 05/29/2025 at 07:58 AM, with the ADON revealed a bottle of omeprazole 20mg with an expiration date of 01/2025, a bottle of omeprazole 20mg with an expiration date of 03/2025, 10 BioSign Flu A+B tests with an expiration date of 07/31/2024, a sterile CleanWipe foam swab with an expiration date of 11/2023, a gray top vacutainer (blood collection device for labs) with an expiration date of 05/31/2024,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for food and nutrition services. The facility failed to ensure the food was safely stored in the freezer and the pantry. This failure could place residents at risk of being served food that could had been crossed-contaminated, frost bitten, and foodborne illness. Findings included: Dry pantry observation on 04/09/2024 at 8:55am revealed an undated plastic container of Fiber. Dry pantry observation on 04/09/2024 at 9:00am revealed an opened bag powered milk, exposed to open air, and not sealed. Refrigerator observation on 04/09/2024 at 8:59am revealed a box of mushrooms in the refrigerator, exposed to open air and not sealed. Kitchen observation on 04/09/2024 at 8:46am revealed a cell phone in a pink protective case sitting on the rolling cart next to the prep table , directly across from the kitchen entry doorway. Kitchen observation on 04/09/2024 at 8:51am revealed a cloudy,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan with resident rights, that include measurable objectives and time frames to meet resident's mental and psychosocial needs for 1 of 4 residents (Resident #39) reviewed for care plans. The facility failed to update Resident #39's care plan to reflect current needs for heel protectors to be worn at all times. This failure placed residents at risk of not receiving the appropriate care and services to maintain the highest practical well-being. Findings included: Review of Resident #39's Face Sheet dated 04/10/2024 revealed a 56 Record review of Resident #80's face-sheet dated 04/09/2024 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: other skin changes (changes in your skin can be clues that there's an internal issue with your health), severe intellectual disabilities (a condition in which your brain doesn't develop properly or function normally),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for two of eight residents (Resident # 40 and Resident # 63) reviewed for quality of life. The facility failed to ensure Resident #40 and Resident #63's nails were cleaned. This failure could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings included: 1. Record review of Resident # 40 Face Sheet dated 04/11/2024 reflected Resident #40 was admitted on [DATE] with diagnosis of muscle weakness (lack of strength in muscles), mild intellectual disabilities (a condition that limits intelligence and disrupts abilities necessary for living independently), and age-related osteoporosis without current pathological fracture (reduce bone mass). Record review of Resident #40's Quarterly MDS Assessment, dated 02/26/2024, reflected resident was rarely/never…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents received care, consistent with professional standards of care to prevent development of pressure ulcers for one of three (Resident # 39) reviewed for pressure ulcers. The facility failed to ensure Resident #39 received his physician ordered heel protectors at all times. This failure could place residents at risk for developing a pressure ulcer leading to pain, discomfort, and potential infections. Findings included: Review of Resident #39's Face Sheet dated 04/10/2024 revealed a 56 -year-old male admitted to the facility on [DATE]. His diagnoses included: other skin changes (changes in your skin can be clues that there's an internal issue with your health), severe intellectual disabilities (a condition in which your brain doesn't develop properly or function normally), and peripheral vascular disease (the reduce circulation of blood to a body part, other than the brain or heart, due to a narrowed or blocked blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to maintain an Infection Control Program designed to ensure hand hygiene procedures were followed by contract staff in the direct care of one of four residents (Resident # 80) reviewed for infection control in that: 1. The facility failed to ensure the Hospice Nurse LVN B sanitized or wash her hands after touching contaminated items while feeding of Resident #80. 2. The facility failed to ensure the Hospice Nurse did not touch Resident #80 tip of straw and side of Resident #80's mouth. These failures could place residents at risk of cross contamination which could result in physical illness. Findings include: Record review of Resident #80's face-sheet dated 04/09/2024 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's disease (parts of the brain that control thought, memory, and language), diseases of lips (can make it difficult to eat, drink, or even smile. Cold sores cause by bacteria…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 one of one kitchen reviewed for sanitation. 1. The DSM failed to ensure all items in the kitchen were labeled, dated, and discarded prior to their expiration date. 2. The DSM failed to ensure all personnel food items were stored separate from resident food items. 3. The DM failed to properly sanitize the thermometer probe when taking the temperature of food items. Findings included: Observations of the reach-in refrigerator on 3/06/2023 from 9:13 a.m. - 9:24 a.m. revealed the following: At 9:13 a.m., the reach-in refrigerator contained 12 bags of yellow unidentifiable substance unlabeled and undated. At 9:15 a.m., the reach-in refrigerator contained five foam containers of unidentifiable substance unlabeled and undated. At 9:16 a.m., the reach-in refrigerator contained three small foam containers of unidentifiable substance unlabeled and undated. At 9:17 a.m., the reach-in refrigerator contained a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three of 24 residents (Residents #55, 57, and 76) and one of four medication carts reviewed for infection control. 1. Resident #55 scratched herself in the perineal area multiple times resulting in soiled hands and fingers, and she touched people and things in the common area without intervention from staff. 2. LVN A stored and locked her used scrub-top in the drawer of a medication cart that contains medications and treatment supplies. 3. LVN C assisted both Residents #57 and 76 with eating, using the same hand, and did not perform hand hygiene between them. These failures placed residents at risk of transmission of infectious diseases. Findings included: Review of the undated face sheet for Resident #55…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 12 of 14 resident rooms (rooms for Residents ##3, 6, 12, 14, 15, 19, 35, 40, 42, 43, 50, 51, 52, 55, 64, 65, 66. 67, 72, 74, 75, and 81) reviewed for physical environment. The air conditioning units in rooms for Residents #3, 6, 12, 14, 15, 19, 35, 40, 42, 43, 50, 51, 52, 55, 64, 65, 74, 75, and 81 were covered with a black and grey substance, and the units in rooms for Residents #52, 64, 65, 66, and 67 were broken and/or not securely fastened to the wall. This failure placed residents at risk of respiratory illness, infection, and injury by accident. Findings included: Review of the undated face sheet for Resident #66 reflected a [AGE] year-old male admitted to the facility on [DATE] and having diagnoses of intellectual disabilities and seasonal allergic rhinitis. Review of the undated face sheet for Resident #67 reflected a [AGE]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one of eight residents (Resident #55) reviewed for care plans. Resident #55 scratched herself in the perineal area multiple times resulting in soiled hands and fingers, and she touched people and things in the common area without intervention from staff, and this was not included in a behavioral care plan. This failure placed residents at risk of not attaining their higest practicable well-being. Findings included: Review of the undated face sheet for Resident #55 reflected a [AGE] year-old female admitted to the facility on [DATE] and having diagnoses of pruritus (itchiness), chronic gingivitis, irritable bowel syndrome, slow transit…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 3 residents (Residents #5) reviewed for pressure ulcers. 1. The facility failed to ensure the provider treatment plan for Resident #5 was implemented. 2. The facility did not provide wound care as ordered by the provider for Resident #5. These failures placed residents at risk of pain, worsening of wounds and wound infection. Findings included: Record review of Resident #5's Face Sheet dated 03/07/23 reflected Resident #5 was a [AGE] year-old male, and he was admitted to the facility on [DATE]. Resident #5 had diagnoses of Dysphagia (difficult to swallow), Parkinsonism, Chronic pain, Deficiency of B and D vitamins, Allergic rhinitis due to pollen, Epilepsy, Constipation, Intellectual disabilities, Muscle Weakness, Need…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.