Marbridge Villa

Inspectors wroteBased on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program to the maximum extent practicable to avoid duplicative testing and effort, which included incorporating the recommendations from the Preadmission Screening and Resident Review level II determination and the Pre-admission Screening and Resident Review evaluation report into a resident's assessment, care planning and transitions of care for one (Resident #1) of six residents reviewed for Pre-admission Screening and Resident Review assessments. The facility failed to provide specialized services to Resident #1 as recommended and agreed upon by the Interdisciplinary Team (IDT).

Inspectors wroteBased 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 food and nutrition services. The facility failed to ensure food was properly labeled and dated in the main cooler and freezer. This deficient practice could place residents at risk for health complications and foodborne illnesses. An observation on 7/07/2026 at 9:05 AM revealed a bag of 12 pressed flour tortillas that were stored without the required labeling and date marking. An observation on 7/7/2026 at 9:06 AM revealed a silver pan of unknown food that was stored without the required labeling and date marking. An observation on 7/7/2026 at 9:06 AM revealed a bottle of sweet Chilli sauce that was stored without the required labeling and date marking. [...]

Inspectors wroteBased 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 2 of 2 residents (Resident #7 and Resident #79) reviewed for infection prevention. 1. The facility failed to ensure CNA C was following the proper infection control protocols while providing incontinent care with Foley catheter to Resident #7. 2. The facility failed to ensure Enhanced Barrier Precautions (EBP) and proper hand hygiene protocols were implemented when LVN A and MA D provided wound care for Resident #79. 3. The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented and used when LVN B and LVN E provided wound care for Resident #79. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident had the right to personal privacy including accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups for 1 of 2 residents (Resident #7) reviewed for privacy. The facility failed to ensure CNA C provided privacy by drawing the privacy curtain during incontinent care for Resident #7. This failure could place residents at risk of feeling embarrassed, diminish the residents' quality of life and not having resident rights acknowledged. Findings Included: Record review of Resident #7's, undated, face sheet reflected a 69-years-old male with an admission date of 12/16/2026. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #17) for incontinence and catheter. The facility failed to ensure CNA C cleaned Resident #7's penis around the catheter while providing incontinent care on 07/07/2026. This failure could place residents at risk of urinary tract infection.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.