Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Marbridge Villa during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, CP, and epilepsy was PASRR positive for ID/DD, and the IDT agreed to specialized services and a pressure-reducing mattress. However, the facility did not timely submit the PASRR NFSS request in the TMHP portal, and PASRR compliance staff documented that no request had been submitted despite the agreed-upon PT, OT, ST, and DME needs.
Food Items Stored Without Required Labels and Dates: Multiple food items in the kitchen cooler and freezer were observed without the required labeling and date marking, including tortillas, an unknown food item, sauce, spinach, macaroni salad, bread, and sausage. Staff interviews confirmed that opened food should be labeled with the date and other required information, and the DSM stated all kitchen items were expected to be labeled and dated per facility practice and policy.
The facility failed to maintain infection control during incontinent care for a resident with a Foley catheter and during wound care for a resident with a heel wound requiring EBP. A CNA did not sanitize hands on entry or exit, handled urine contamination and incontinent care with poor glove and wipe technique, and did not clean the Foley catheter or complete full perineal care. An LVN and a CMA also entered an EBP room without hand hygiene or gowns, and wound care staff did not consistently perform hand hygiene, use required PPE, or disinfect reusable wound care items before returning them to the cart.
Failure to Provide Privacy During Incontinent Care: A CNA provided incontinent care to a resident with a Foley catheter and frequent incontinence while the resident was nude from the waist down and the privacy curtain was not drawn, even though the roommate was present in the room. The CNA said she forgot to pull the curtain, and the DON and ADON stated privacy curtains were expected during resident care as a dignity issue; the facility policy for catheter care also directed staff to provide privacy.
Failure to provide proper Foley catheter and incontinent care for a resident with severe cognitive impairment and urinary retention. CNA C observed providing care to a male resident with an indwelling catheter did not clean the penis around the catheter before applying clean briefs. CNA C stated staff were expected to clean the penis and catheter area during incontinent care, and the DON and ADON confirmed staff should wipe the catheter away from the insertion site to help prevent infection and UTI.
PASRR Coordination and Specialized Services Not Timely Submitted
Penalty
Summary
The facility failed to coordinate assessments with the PASRR program to the maximum extent practicable and did not incorporate the recommendations from the PASRR Level II determination and evaluation report into the resident’s assessment, care planning, and transitions of care. The resident was a re-admitted male with diagnoses including Cognitive Communication Deficit, Cerebral Palsy, and Lennox-Gastaut Syndrome. His annual MDS reflected severe cognitive impairment with a BIMS score of 3, dependence for eating, toileting hygiene, showering/bathing, and personal hygiene, and need for assistance with transfers and ambulation. He used a manual wheelchair. Record review showed the resident was identified as PASRR positive for intellectual disability and developmental disability. The PASRR evaluation meeting documented that Medicaid eligibility was confirmed and that specialized services and a specialized or treated pressure-reducing support surface mattress were approved. The initial care plan meeting included the resident’s family member and the PASRR Habilitation Coordinator, and the IDT determined it would continue to monitor and assist. The care plan also reflected PASRR positive status and listed specialized services of PT, OT, and ST, along with interventions related to activities and mobility. Despite the IDT agreement, the facility did not submit the PASRR NFSS request within the required timeframe for the specialized services and DME. An email from PASRR Support stated that no NFSS request had been submitted even though the services and DME products were recommended and agreed upon by the SP team. Facility staff gave differing accounts of who was responsible for submitting the request and adjusting information in the TMHP portal. The PASRR compliance unit notified the facility that it was out of compliance with the PASRR timeline, and the facility later sent information stating the resident no longer required the requested DME.
Food Items Stored Without Required Labels and Dates
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen. During observations in the main cooler and freezer, multiple food items were found without the required labeling and date marking, including a bag of 12 pressed flour tortillas, a silver pan of unknown food, a bottle of sweet Chilli sauce, a large bag of spinach, a large silver pan of macaroni salad, a large frozen package of single serve bread, a small package of bread, and a frozen package of hot link sausage. During interviews, the DA F stated food items should be labeled when opened and that labels should include the open date, expiration date, and initials. DA G stated food items should be labeled when opened and should include the date, item name, and expiration date. The DSM stated it was her expectation that all items in the kitchen be labeled and dated, with labels including the date, item name, initials, expiration date, and throw out date. Record review of the facility's Food Storage policy stated leftover food should be stored in covered containers or wrapped securely and clearly labeled and dated before refrigeration, and that leftover food must be used within 7 days or discarded.
Infection Control Failures During Foley Care and Wound Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for two residents reviewed for infection prevention. One resident had diagnoses including urinary tract infection, urinary retention, presence of urogenital implants, benign prostatic hyperplasia, and cognitive communication deficit, and required intermittent catheterization and frequent incontinent care. During observation of incontinent care, a CNA entered the room without sanitizing her hands, put on PPE, assisted the resident from wheelchair to bed, and handled a leaking Foley bag that had urine on the floor. She wiped the urine with paper towels and discarded them in the bathroom trash, then performed incontinent care while using multiple wipes at once, leaving dirty wipes between the resident’s legs, not cleaning the Foley catheter, and not cleaning the resident’s left buttocks and anal area. She removed and replaced gloves without hand hygiene and exited the room without washing or sanitizing her hands. The second resident had diagnoses including expressive language disorder, hemiplegia and hemiparesis on the left side, cognitive communication deficit, and need for assistance with personal care. The resident had a left heel wound and required Enhanced Barrier Precautions. During observed wound care, an LVN and a CMA entered the room without sanitizing their hands and without gowns. The LVN donned gloves without hand hygiene, sanitized the overbed table, and placed wound care supplies on it. She removed the wound dressing without removing gloves or performing hand hygiene, opened supplies while still gloved, then removed gloves and sanitized her hands before cleaning the wound. She applied the new dressing while wearing gloves, and both staff removed gloves and discarded them without washing their hands afterward. The LVN then took a reusable tray with remaining wound care supplies and scissors out of the room and placed it in the treatment cart without disinfecting the tray or reusable items. A later observation showed the same resident again receiving wound care in an EBP room, with an LVN and another LVN wearing gloves but not gowns. Interviews with staff and leadership reflected that staff were expected to sanitize hands before entering and after leaving resident rooms, use gowns and gloves for wound care in EBP rooms, and clean reusable wound care supplies before returning them to the cart. The facility’s policies stated that EBP includes gown and glove use for wound care involving any skin opening requiring a dressing, and that catheter care and wound care require hand hygiene and proper cleaning steps. The observed care did not follow those protocols.
Failure to Provide Privacy During Incontinent Care
Penalty
Summary
The facility failed to ensure privacy during incontinent care for a resident who had diagnoses including urinary tract infection, presence of urogenital implants, urinary retention, unspecified intellectual disability, benign prostatic hyperplasia, and cognitive communication deficit. The resident’s quarterly MDS reflected moderately impaired cognitive skills for daily decision making, substantial/maximal assistance needed with toileting hygiene and showering/bathing, and that he required intermittent catheterization and was frequently incontinent. His care plan and order summary included Foley catheter care every shift and monthly catheter and drainage bag changes. During an observation of perineal care with an indwelling catheter, a CNA provided incontinent care while the resident was nude from the waist down and did not pull the privacy curtain. The resident’s roommate was present in the room during the care. During interview, the CNA stated she forgot to pull the privacy curtain and acknowledged the roommate could have been uncomfortable seeing the resident exposed. The DON and ADON stated staff were expected to pull privacy curtains during resident care because it was a dignity issue and residents could become embarrassed and upset. The facility policy for catheter care stated to provide privacy.
Failure to Provide Proper Foley Catheter and Incontinent Care
Penalty
Summary
The facility failed to ensure a resident with an indwelling Foley catheter received appropriate incontinent care and catheter care to prevent urinary tract infection and to support continence to the extent possible. Resident #7 was a male with diagnoses including urinary tract infection, urinary retention, benign prostatic hyperplasia, metabolic encephalopathy, microcephaly, intellectual disabilities, and cognitive communication deficit. His quarterly MDS reflected a BIMS score of 03, indicating severe cognitive impairment, and he required substantial to maximal assistance with bathing. His care plan directed staff to provide Foley catheter care every shift and to monitor for signs and symptoms of UTI. During observation of incontinent care, CNA C washed her hands, donned gloves, removed the resident’s briefs, and placed wipes beside the resident, but did not clean the penis around the Foley catheter before applying clean briefs and assisting the resident to his wheelchair. During interview, CNA C stated that when providing incontinent care for a male with a Foley catheter, staff were expected to clean the penis and catheter area, and she could not recall whether she had cleaned Resident #7’s Foley catheter. The DON and ADON stated staff were expected to wipe the Foley catheter away from the insertion site at the penis during incontinent care to prevent infection problems and potential UTIs. The facility’s catheter care policy also directed staff to provide routine perineal hygiene and, for a male resident with an indwelling catheter, to hold the tubing to one side and support it against the leg to avoid traction or unnecessary movement.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 240 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Manchaca
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brodie Ranch Nursing And Rehabilitation Center | 1.3 mi | ★★★★★ | 11 | 1 |
| West Oaks Nursing And Rehabilitation Center | 3.1 mi | ★★★★★ | 13 | 0 |
| Onion Creek Nursing And Rehabilitation Center | 3.6 mi | ★★★★★ | 2 | 0 |
| Southpark Meadows Nursing And Rehabilitation Cente | 3.8 mi | ★★★★★ | 7 | 0 |
| Brush Country Nursing And Rehabilitation | 6.1 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Marbridge Villa.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.