Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 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.
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 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 | — | 0 | 0 |
| Hubble Creek | 10.9 mi | — | 10 | 0 |
| Fountainbleau Lodge | 14.4 mi | — | 0 | 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 August 2026) and official state health department websites.