Stonebridge Health & Rehabilitation Center

Based on observations, clinical record review, review of facility documents, and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of 18 residents reviewed (Resident 11). Findings Include: Review of Resident 11's clinical record revealed diagnoses that included COPD (chronic obstructive pulmonary disease- a progressive, inflammatory lung disease that blocks airflow and makes breathing difficult) and anxiety. During an interview with Resident 11 on June 8, 2026, at 10:34 AM, Resident 11 stated that she was missing her left hearing aid. Observation of Resident 11 at that time revealed she did not have a hearing aid in either ear. Review of facility's grievance log revealed a grievance filed by Resident 11, on January 6, 2026, stating that Resident 11 was missing her hearing aid. The grievance did not specify if it was the right or left hearing aid that was missing. The plan was for the facility to replace the hearing aid. Further review of the grievance form revealed…

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 facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the resident right to receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of 18 residents reviewed (Resident 1). Findings include: Review of facility policy, titled Cardiopulmonary Resuscitation CPR Policy last reviewed March 16, 2026, read, in part, At admission, facility staff should confirm whether the resident has advance directives and identify the resident/legal representative's preferences regarding CPR (Cardiopulmonary Resuscitation, an emergency procedure used to maintain blood flow and oxygen to vital organs when the heart stops beating). This review may occur as part of the admission assessment. If physician order(s) differ from the resident's wishes or there are no physician orders present: Promptly contact the provider for an appropriate order. Review of Resident 1's clinical record revealed diagnoses that included…

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 facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one of two residents reviewed for limited range of motion (Resident 8).Findings include: Review of facility policy, titled Restorative Nursing Referral Process & Policy last reviewed February 24, 2026, read, in part, Procedure: The referral form is filled out by the referring therapist and given to the Director of Rehab. Residents who could benefit from restorative programs (RNP) include but are not limited to: residents who are ready to finish a program of skilled rehabilitation therapy. Referral to restorative should be generic, not complicated, or should be reconsidered to stay on therapy. Review of Resident 8's clinical record revealed diagnoses that included infection and inflammatory reaction due to internal right hip prosthesis (infection of artificial hip joint that can cause pain and swelling) and generalized…

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, facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure staff implement transmission-based precautions to prevent the spread of infection for one of two residents (Resident 36) on transmission-based precautions.Findings Include: Review of facility policy, titled Transmission-Based Precautions and Isolation Policy, revised April 15, 2026, revealed, Contact Precautions - intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the patient or the patient's environment. Review of Resident 36's clinical record revealed diagnoses that included giardia (an infection of the small intestine) and urinary tract infection (UTI- is a bacterial infection in the urinary system [kidneys, bladder, or urethra]). Observation of Resident 36 on June 9, 2026, at 8:50 AM, revealed Resident 36 lying in her bed. Hanging on the wall outside of Resident 36's room was a sign indicating that Resident 36 was on contact precautions and that anyone entering the room was required…

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, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to maintain an effective infection control program related to the preparation and administration of medications for two of two residents observed; failed to ensure staff implemented infection control policies to prevent the spread of infection for one of 19 residents reviewed; and failed to maintain an accurate data collection system of infection surveillance from October 2024 through March 2025. Findings Include: Review of facility policy, titled 6.0 General Dose Preparation and Medication Administration, last revised November 15, 2024, revealed it stated, 1.2 Medications should not come in contact with any surface except for the medication cup .2.3 Facility staff should avoid touching the medication with bare hands when opening a bottle or unit dose package . Review of facility policy, titled Enhanced Barrier Precautions (EBP) Policy, revised May 19, 2025, revealed EBP are intended to prevent transmission of multi-drug-resistant organisms (MDROs)…

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, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection of a pressure ulcer for one of 16 residents reviewed (Resident 47). Findings include: Review of Resident 47's clinical record revealed diagnoses that included chronic kidney disease (a gradual loss of kidney function) and hyperlipidemia (high levels of fat in the blood). Review of Resident 47's clinical record revealed an active physician's order for prevalon boots on at all times every shift, with a start date of October 9, 2024. Observations of Resident 47 on June 30, 2025, at 12:15 PM and 2:16 PM, revealed the Resident was sitting in their wheelchair wearing sneakers instead of prevalon boots. Observation of Resident 47 on July 1, 2025, at 12:03 PM and 2:26 PM, revealed the Resident sitting in their wheelchair wearing sneakers instead of prevalon boots. Review of Resident 47's Medication Administration Record…

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, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one of three residents reviewed for mobility (Resident 48). Findings Include: Review of Resident 48's clinical record revealed diagnoses that included stroke and elevated blood pressure. Review of Resident 48's current physician orders revealed an order, with a start date of October 15, 2024, for left hand splint, on at all times, may remove for care and to remove splint every shift to observe and monitor for skin breakdown. Review of Resident 48's current care plan revealed left hand splint on at all times, remove splint every shift and observe and monitor for skin breakdown, dated October 15, 2024. Observations of Resident 48 on June 30, 2025, at 10:14 AM, 12:37 PM, 1:39 PM, and on July 1, 2025, at 11:04 AM and 12:05 PM, revealed Resident 48's left hand splint was not in place. During an interview with Resident 48 on July 1,…

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 facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to provide routine drugs and biologicals to its residents and 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 three of seven residents reviewed (Residents 1, 2, and 3). Findings include: Review of facility policy, titled Delivery and Receipt of Routine Deliveries subsection Long-Term Care Facilities Receiving Products and Services from Pharmacy last revised August 1, 2024, read, in part, Receipt of Medications and Supplies: A facility nurse should inspect the package(s) for any damage or errors and notify pharmacy as soon as possible but within twenty-four hours of any damage or other discrepancies. If any item ordered by the facility is not received in the delivery, facility staff should check for a pharmacy slip explaining the reason 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.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing of a pressure ulcer for one of two residents reviewed for pressure ulcers (Resident 6). Findings include: Review of facility policy, titled Clean Dressing Change Policy last revised, March 10, 2024, read, in part, Wounds will be dressed using a clean technique which avoids direct contamination of material and supplies. Apply new dressings as ordered. Document procedure and update findings. Review of Resident 6's clinical record revealed diagnoses that included pressure ulcer of right heel (wound that occurs when the skin and tissue are damaged by prolonged pressure) and osteoarthritis (a type of arthritis that affects the joints in your body). Review of Resident 6's physician orders revealed the following pressure wound order: Treatment as follows: Cleanse right heel with soap & water, pat dry. Apply betadine then calcium…

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 facility policy, clinical record review, and staff interviews, it was determined that the facility failed to provide services necessary to maintain adequate personal grooming of residents dependent on staff for assistance with these activities of daily living for two of six residents reviewed (Residents 3 and 4). Findings Include: Review of the facility policy, titled Resident Bath/Showering/Scheduling Policy with a last revised date of September 9, 2022, revealed (A) Each resident will be asked about his/her bathing preferences upon admission (type of bath, preferred days and times), (H) If the bath/shower cannot be given or the resident refuses, the nursing assistant will promptly report this to the Charge Nurse, and (I) The Charge Nurse will speak with the resident who refuses to ascertain why they are refusing and to determine if alternate arrangement that suit the resident can be made. If the resident continues to refuse the Charge Nurse document the resident's refusal in the medical record. Review of Resident 3's clinical record revealed diagnoses that included…

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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to include reconciliation of all pre-discharge medications with the resident's post-discharge medications in the resident's discharge summary for one of three closed records reviewed (Resident 55). Findings Include: Review of facility policy, titled Discharge Planning Policy, revised September 24, 2020, revealed When a discharge is anticipated, [Facility] will develop a discharge summary/instructions that includes, but is not limited to, the following: .Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter.) Review of Resident 55's clinical record revealed diagnoses that included cerebral infarction (stroke - occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) and anxiety (a feeling of fear, dread, and uneasiness). Further review of Resident 55's clinical…

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 clinical record review and resident and staff interviews, it was determined that the facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one of three residents reviewed for mobility (Resident 22). Findings Include: Review of Resident 22's clinical record revealed diagnoses that included hypertension (elevated blood pressure), congestive heart failure (CHF- a chronic condition in which the heart doesn't pump blood as well as it should), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). During an interview with Resident 22 on June 10, 2024, at 10:38 AM, she stated that she wants to walk at least once a day, but stated that staff don't always assist her in doing so. During the resident group interview on June 11, 2024, at 11:00 AM, Resident 22 again expressed concern with her walking program and not being assisted with walking every day. Review of Resident 22's facility form, titled Restorative Ambulation Program Referral, dated…

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 review of facility policy, observations, and staff interviews, 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 one of 21 residents on transmission-based precautions (Residents 46). Findings include: Review of facility policy, titled Transmission-Based Precautions Isolation Policy, revised April 15, 2024, read, in part, contact precautions also apply where there is urinary incontinence or other discharges from the body suggest an increased potential for environmental contamination and risk of transmission. Personal Protective Equipment (gloves, gown, face mask, face shield) recommended: gloves whenever touching the resident's intact skin or surfaces and articles in close proximity to the resident. Gowns whenever anticipating that clothing will have direct contact with the resident or potentially contaminated environmental surfaces. Review of Resident 46's revealed diagnoses…

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.