Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Stonebridge Marble Hill during CMS and state inspections, most recent first.
Failure to obtain and document informed consent for psychotropic meds affected three residents. One resident with spinal cord injury, quadriplegia, PTSD, and major depressive disorder had Seroquel ordered for PTSD; another resident with schizophrenia had Risperdal ordered; and a third resident had Seroquel ordered twice daily. Records lacked documentation of consent or education on risks and benefits, and the residents and a spouse did not recall reviewing medication risks, benefits, side effects, or other treatment options with staff.
Failure to attempt GDR for psychotropic meds: two residents remained on antipsychotic therapy without required GDR documentation. One resident with bipolar disorder, dementia, PTSD, anxiety, Parkinson's disease, and polyneuropathy had Abilify 15 mg daily with pharmacist requests to reduce the dose, but no physician response or proof the requests were sent. Another resident with schizophrenia, MDD, PTSD, Parkinson's disease, restless leg syndrome, and cerebral infarction had Risperdal 1 mg daily with no documentation of a GDR request, GDR attempt, or clinical contraindication.
Failure to provide written transfer, bed hold, and discharge documentation. Four residents had hospital transfers with no record that the resident or representative received written transfer notices or bed hold notices, including the daily bed hold rate. A resident discharged to the community also had no recapitulation of stay completed or provided. RN and admin interviews confirmed the missing paperwork and that staff expected these notices and summaries to be completed.
Missed Resident Showers: The facility failed to provide or document scheduled showers for multiple residents who needed assistance with bathing, including residents with dementia, Parkinson's disease, hemiplegia, schizophrenia, epilepsy, depression, fractures, transverse myelitis, osteoarthritis, lymphedema, Alzheimer's disease, osteoporosis, and hypertension. Records showed repeated missed showers despite schedules for two to three showers per week, and CNAs and the DON described a system of assigned shower days, makeup days, and electronic documentation that did not reflect the missed care.
Infection control failures occurred during wound care and blood glucose testing. An LPN performed wound care for two residents without consistent hand hygiene or glove changes between contaminated and clean tasks, and touched resident items before exiting. A CMT used the same glucometer for multiple residents without cleaning and disinfecting it between uses, did not perform hand hygiene at key points, and removed test strips with bare hands.
A CNA did not receive the required annual in-service education or the mandatory competency training in abuse prevention and dementia care. Facility records showed no in-service training for the CNA during the review period, and the Administrator stated CNAs were expected to complete at least 12 hours of annual education, including the required competency topics.
A resident, dependent on staff for transfers, was injured when two CNAs manually transferred them without using the required mechanical lift, as specified in the care plan. The resident, with a history of cervical fracture and other conditions, sustained a hematoma on the chest, requiring emergency evaluation. The CNAs were suspended pending investigation.
A resident with multiple diagnoses, including schizophrenia and bipolar disorder, was sent to the hospital for a psychiatric evaluation after expressing suicidal thoughts. Despite being cleared to return with medication adjustments, the facility refused re-admission, citing the need for inpatient psychiatric care. The facility did not issue a discharge notice or assist in finding alternative placement, leaving the resident in the ER for two weeks.
The facility failed to provide timely written notification to residents and their representatives regarding hospital transfers. Seven residents experienced multiple transfers without documented notifications. The Administrator acknowledged the expectation for written notice, but the facility lacked a policy for transfer/discharge notification, leading to the deficiency.
The facility failed to notify residents and/or their representatives in writing of the bed hold policy during hospital transfers for five residents. Despite the facility's policy requiring written notification upon transfer, there was no documentation for these instances. The Administrator claimed to have mailed the notices and noted them in the charts, but this was not evident in the records.
The facility failed to develop comprehensive care plans for two residents. One resident with Parkinsonism lacked a care plan addressing the condition, while another with a mediport had no care plan for its management. The interdisciplinary team did not update care plans to reflect current conditions, as confirmed by staff interviews.
A facility failed to establish orders and protocols for the care and maintenance of a resident's mediport. The resident had a mediport for years due to poor veins, but there were no documented orders or assessments for its use. Only the DON knew how to access the mediport, which was used for drawing lab work. The resident's care plan did not address the mediport, and the DON expected such protocols to be in place.
The facility exceeded the acceptable medication error rate, reaching 13.95%, due to improper insulin administration. A CMT failed to prime insulin pens before use, affecting six residents. The CMT was unaware of the priming requirement, and the facility lacked a policy for insulin pen use.
The facility failed to maintain an Infection Prevention and Control Program, including an antibiotic stewardship program, affecting all 82 residents. The former DON, responsible for the program, quit suddenly, taking all documentation. The current DON could not find any records, leading to the deficiency.
Failure to Obtain and Document Psychotropic Medication Consent
Penalty
Summary
The facility failed to ensure informed consent was obtained and documented for psychotropic medication use for three sampled residents. Review of the facility policy titled, Psychotropic Medication Use, stated psychotropic medications are to be prescribed at the lowest possible dosage for the shortest period of time and that the attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks. However, the records reviewed did not include documentation of consents or education regarding the risks and benefits of psychotropic medications for Residents #8, #10, and #61. Resident #8 had diagnoses including spinal cord injury, quadriplegia, PTSD, and major depressive disorder, and had an order for Seroquel 50 mg daily related to PTSD. Resident #10 had schizophrenia and an order for Risperdal 1 mg daily related to schizophrenia. Resident #61 had an order for Seroquel 25 mg in the morning and 50 mg at bedtime. During interviews, Resident #8 did not remember whether risks and benefits were reviewed, Resident #10 did not remember receiving medication consent forms or a review of risks and benefits, and Resident #61 and the resident's spouse did not recall signing a consent form or discussing the medication, side effects, or other treatment options. The Administrator and DON stated they would expect signed psychotropic consent forms when psychotropic medications were started or adjusted.
Failure to Attempt GDR for Psychotropic Medications
Penalty
Summary
The facility failed to attempt a gradual dose reduction (GDR) for psychotropic medications for two residents. The facility policy titled, Psychotropic Medication Use, stated psychotropic medications should be prescribed at the lowest possible dosage for the shortest period of time and are subject to GDR and re-review, and that the physician should respond by changing or stopping problematic doses or clearly documenting why the benefits outweigh the risks or adverse consequences. One resident admitted with Parkinson's disease, polyneuropathy, dementia, bipolar disorder, PTSD, and anxiety disorder had an order for Abilify 15 mg daily for bipolar disorder, but the record showed GDR requests from the pharmacist to reduce the dose to 10 mg on two occasions without physician response or documentation that the requests were sent to the physician. Another resident admitted with cerebral infarction, MDD, PTSD, restless leg syndrome, schizophrenia, and Parkinson's disease had an order for Risperdal 1 mg daily for schizophrenia, but there was no documentation of a pharmacist GDR request, a GDR attempt, or that GDR was considered clinically contraindicated for the medication. During interviews, the Administrator, DON, and Pharmacist stated GDRs should be completed when due and that pharmacy recommendations were sent monthly for physician review.
Failure to Provide Written Transfer, Bed Hold, and Discharge Documentation
Penalty
Summary
The facility failed to provide required written notice and documentation related to resident transfers, discharge, and bed hold policy requirements for four residents. Review of the facility’s bed hold policy showed that residents or their representatives were to receive written information about the bed hold policy at admission and when transferred for hospitalization or therapeutic leave, including the covered service for Medicaid state plan bed holds and any non-covered days with the option to pay for additional days. Review of the transfer or discharge notice policy showed that residents and/or representatives were to be notified in writing of the reason for transfer or discharge, the effective date, and the location of the transfer or discharge. For Residents #1, #3, #13, and #70, records showed multiple hospital transfers and returns to the facility, but there was no documentation that written transfer notifications or bed hold notices, including the daily bed hold rate, were provided to the resident and/or representative for those transfers. During interview, RN E stated nurses were responsible for completing transfer and bed hold documentation in the electronic record, printing it to send with the resident to the hospital, and notifying the appropriate people, but no paperwork would be provided to the resident representative. The Administrator stated she would expect residents or their representatives to be informed in writing of transfers and the bed hold policy along with the daily bed hold rate. In addition, Resident #72 was admitted and later discharged to the community, but the record showed no documentation that a recapitulation of stay was completed and provided to the resident and/or representative. The Administrator stated the facility did not have a recapitulation of stay completed for this resident, and the Administrator and DON stated they would expect a recapitulation of stay to be completed when a resident was discharged.
Missed Resident Showers
Penalty
Summary
The facility failed to provide showers for six sampled residents who were assessed as needing assistance with showering or bathing. The residents had diagnoses including cognitive impairment, dementia, Parkinson's disease, hemiplegia, aphasia, schizophrenia, epilepsy, depression, fractures, transverse myelitis, osteoarthritis, lymphedema, Alzheimer's disease, osteoporosis, hypertension, and other chronic conditions. Several of the residents were dependent on staff or required partial to substantial assistance for showering/bathing according to their MDS assessments. Review of shower schedules and shower documentation showed repeated missed showers for each of the six residents. Resident #5 missed five scheduled showers across December and January; Resident #7 missed nine scheduled showers across the same period; Resident #19 missed five scheduled showers; Resident #31 missed eight scheduled showers; Resident #41 missed four scheduled showers; and Resident #61 missed three scheduled showers in December. The records showed that these residents were scheduled for showers two to three times per week, with some having a makeup shower day on Sunday, yet the documented showers were not consistently completed. During interviews, CNAs stated that showers were assigned by hall and were to be offered two to three times weekly, with Sunday used as a makeup day for missed or refused showers. The DON stated completed shower sheets were not kept for more than seven days and that the electronic record only allowed a 30-day look back for shower review. The Administrator and DON stated they expected residents to be given or offered a minimum of two showers per week and that showers should be documented in the electronic medical record.
Infection Control Failures During Wound Care and Blood Glucose Testing
Penalty
Summary
The facility failed to use proper infection control techniques during wound care for two residents and during blood glucose testing for four residents. The report states that the facility’s hand hygiene policy required staff to perform hand hygiene before putting on gloves, immediately after removing gloves, between resident contacts, after handling items potentially contaminated with body fluids, and when moving from a contaminated body site to a clean site. The facility’s glucometer disinfection policy and the glucometer manufacturer’s instructions also required cleaning and disinfection of the meter after use on each resident, along with hand hygiene before proceeding to the next resident. During wound care for one resident with EBP signage in place, an LPN entered the room, performed hand hygiene, and put on gloves, but did not put on a gown. The LPN cleaned the resident’s buttocks, changed gloves without performing hand hygiene, then cleaned the sacral wound and applied multiple treatments, including skin prep, Iodosorb, collagen powder, calcium alginate, island dressing, and Calmoseptine cream, without changing gloves or performing hand hygiene between tasks. The LPN also put on a clean brief, removed gloves without performing hand hygiene, touched the resident’s call light, bed control, and blankets, and then performed hand hygiene before exiting the room. During wound care for another resident with EBP signage in place, the same LPN put on a gown and mask, performed hand hygiene, and put on gloves, but then removed the resident’s brief and continued wound care without changing gloves or performing hand hygiene. The LPN cleaned the wound, applied collagen powder and Calmoseptine cream without changing gloves or performing hand hygiene, and touched the resident’s blankets and bed control before removing gloves and gown and performing hand hygiene. The LPN later stated that hands should be cleaned before and after wound care and that gloves should be changed when soiled. During blood glucose testing for four residents, a CMT removed the same glucometer from a scrub pocket and placed it on top of the medication cart without a clean barrier, did not clean and disinfect the glucometer between residents, and did not perform hand hygiene before putting on gloves. The CMT entered each resident’s room, performed the blood glucose test, exited without changing gloves or performing hand hygiene, then removed the blood glucose strip from the glucometer with bare hands. The glucometer was again placed in the scrub pocket without cleaning and disinfection. During interview, the CMT stated that hand hygiene was performed between every task and every resident, that gloves were worn during testing and strip removal, and that the glucometer was wiped with a Super Sani-Cloth Germicidal Disposable Wipe and allowed to sit for two minutes; however, the observations showed these actions were not performed.
Nurse Aide In-Service and Competency Training Deficiency
Penalty
Summary
The facility failed to conduct at least 12 hours of annual nurse aide in-service education and failed to provide the required competency training in Abuse Prevention and Dementia Care for one sampled CNA, CNA B. The facility policy required at least 12 hours of in-service training annually based on the employment date and included dementia management and care of cognitively impaired residents as well as abuse, neglect, and exploitation prevention. Review of CNA B’s in-service record showed a hire date of 01/16/19, no annual competency in-service training on Abuse and Neglect Prevention, no annual competency in-service training on Dementia Care, and no in-service training from January 2025 through January 2026. During interview, the Administrator stated she would expect CNAs to have at least 12 hours of in-service education per year, including the mandatory annual competency trainings.
Failure to Follow Care Plan Results in Resident Injury
Penalty
Summary
The facility failed to adhere to a resident's care plan, which required the use of a mechanical lift for transfers. Instead, two Certified Nurse Assistants (CNAs) transferred the resident manually, resulting in the resident sustaining a hematoma on the chest. The resident, who was moderately cognitively impaired and totally dependent on staff for transfers, was not transferred according to the care plan, which specified the use of a mechanical lift with the assistance of two staff members. The resident's medical history included a fracture of the sixth cervical vertebra, hemiplegia, chronic obstructive pulmonary disease, dysphagia, and muscle weakness. The resident was found with a swollen and bruised area on the right upper chest, which was painful and required evaluation at an emergency room. A CT scan confirmed a probable hematoma within the anterior right chest wall. Interviews revealed that the CNAs involved did not follow the care plan, with one CNA stating that the resident had agreed to the manual transfer, which the resident later denied. The CNAs were suspended pending investigation, and the incident was reported to the facility administration. The failure to use the mechanical lift as required by the care plan led to the resident's injury.
Failure to Re-admit Resident After Hospitalization
Penalty
Summary
The facility failed to allow a resident to return after being sent to the hospital for a psychiatric evaluation. The resident, who had multiple diagnoses including spina bifida, schizophrenia, and bipolar disorder, was sent to the hospital after expressing suicidal thoughts. Despite being cleared by a psychiatrist to return to the facility with medication adjustments, the facility refused to readmit the resident, citing the need for an inpatient psychiatric stay. The facility's policies on bed holds and discharges were not followed, as no official discharge notice was given to the resident or their representative. The facility did not assist in finding alternative placement for the resident, who remained in the emergency room for two weeks without being admitted to the hospital. The facility's medical director and DON decided not to readmit the resident, stating that the facility could not provide the necessary 1:1 suicidal watch care. Interviews with facility staff and hospital personnel revealed that the facility did not initiate the discharge process or issue a discharge notice. The resident was eventually accepted by another skilled nursing facility. The facility's actions and inactions led to the resident being left in the emergency room without proper discharge procedures being followed.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents and their representatives regarding transfers or discharges to the hospital. This deficiency was identified for seven residents out of a sample of ten, with the facility's census being 82. The medical records of these residents showed multiple instances of hospital transfers without documented written notifications. For example, one resident was transferred to the hospital on four separate occasions, and another on six occasions, without any written notification being provided to the resident or their representative. During an interview, the Administrator acknowledged the expectation that written notice of a resident's transfer or discharge should be given to the resident and/or their representative and documented in the resident's medical record. However, the facility did not provide a policy for transfer/discharge notification, indicating a systemic issue in adhering to notification requirements. This lack of documentation and policy adherence led to the deficiency noted by the surveyors.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility failed to notify residents and/or their representatives in writing of the bed hold policy at the time of transfer to the hospital for five residents out of ten sampled. The facility's policy, dated March 2022, requires that upon admission and during transfers to hospitalization or therapeutic leave, residents or their representatives must be informed in writing about the bed hold policy. In cases of emergency transfers, this information should be provided within 24 hours. However, for Residents #21, #31, #33, #36, and #55, there was no documentation indicating that the bed hold policy was communicated in writing during their hospital transfers. Resident #21 experienced multiple hospital transfers on specific dates, yet there was no record of written notification regarding the bed hold policy. Similarly, Resident #31 was transferred to the hospital without documented written notification. Resident #33, who was transferred in October 2023, also lacked documentation of being informed in writing. Resident #36 had two hospital transfers, and Resident #55 had two as well, with no written notifications documented for any of these instances. During an interview, the Administrator stated that she filled out the Bed Hold Notice form, mailed it to the resident's representative, and noted it in the resident's chart, but this was not reflected in the records reviewed.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, which was identified during a survey. Resident #33, who was diagnosed with Parkinsonism and admitted to hospice care, did not have a care plan addressing the condition, including associated risks, goals, and interventions. This oversight was noted despite the facility's policy requiring the interdisciplinary team to create person-centered care plans that incorporate the resident's strengths, needs, and preferences. Similarly, Resident #35, who had a mediport due to poor veins and difficulty with blood draws or IV access, did not have a care plan that addressed the mediport, including its risks, goals, and necessary interventions. The absence of documentation for assessments, orders to access, or protocols to maintain the mediport was observed. Interviews with the DON, MDS Coordinator, and Administrator confirmed that the interdisciplinary team was responsible for care plan development and revisions, which should reflect the resident's current condition.
Lack of Mediport Care Protocols
Penalty
Summary
The facility failed to have an order and a process in place for accessing, maintaining, and assessing a mediport for one resident. The resident had a right-sided mediport catheter, as indicated by a CT scan report, but there were no orders or protocols for its access and maintenance, nor documentation for its assessments. The resident's care plan did not address the mediport, including its risks, goals, and interventions. During an observation, the mediport was noted on the resident's right upper chest. The resident mentioned that staff accessed the mediport to draw lab work, and only one staff member knew how to access it. The Director of Nursing confirmed she was the only person who knew how to access and draw blood from the mediport and expected there to be orders and assessments for its care and maintenance.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Insulin Administration
Penalty
Summary
The facility failed to maintain a medication error rate of five percent or less, resulting in a 13.95% error rate. This deficiency was identified through observation, interview, and record review, affecting six residents out of ten sampled. The errors were primarily related to the improper administration of insulin using pen-type devices, where the Certified Medication Technician (CMT) failed to prime the insulin pens before administration, as required by the manufacturer's instructions. This failure to prime the pens could lead to incorrect dosing of insulin, as air may collect in the cartridge during normal use. The specific incidents involved residents receiving insulin doses without the pens being primed, despite clear instructions from the manufacturers of Novolog, Humalog, and Fiasp insulin pens. The CMT involved was unaware of the need to prime the pens, which was confirmed during an interview. The facility did not have a policy for insulin pens, and the administrator acknowledged the expectation that manufacturer's guidelines should be followed when administering insulin with an insulin pen.
Failure to Maintain Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an Infection Prevention and Control Program (IPCP) that included an antibiotic stewardship program, which had the potential to affect all 82 residents. The facility's policy, dated 2018, required adherence to national standards to prevent and control infections, including an antibiotic stewardship program. However, the facility did not provide documentation for this program. The Director of Nursing (DON) or designee was responsible for tracking antibiotic use and monitoring adherence to evidence-based criteria, as per the 2017 policy. The deficiency arose when the former DON/Infection Preventionist, who was responsible for the antibiotic stewardship program, quit suddenly in August 2024, taking all related documentation. The current DON was unable to locate any documentation for the program.
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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 Marble Hill
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jackson Manor | 8.8 mi | ★★★★★ | 9 | 0 |
| Hubble Creek | 10.9 mi | ★★★★★ | 10 | 0 |
| Fountainbleau Lodge | 14.4 mi | ★★★★★ | 7 | 0 |
| Heartland Care And Rehabilitation Center | 14.9 mi | ★★★★★ | 4 | 0 |
| Chaffee Nursing Center | 15.1 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 July 2026) and official state health department websites.