Stonebridge at Montgomery Health Care Center

Inspectors wroteBased on observation, interview, record review, and review of pertinent documents, it was determined that the facility failed to: a.) adequately monitor and supervise a resident (Resident #15) who was identified as a high fall risk and sustained nine unwitnessed falls with four falls that resulted in injuries that required hospitalization which included; an intracranial bleed (brain injury) and a laceration that required seven sutures (stitches), a fracture to the left hip requiring surgical repair (Open Reduction and Internal Fixation - ORIF), a hematoma (collection of blood outside the blood vessels similar to a bruise) and laceration to the back of the head that was closed with stitches, and a right hip fracture; [...]

Inspectors wroteComplaint #: NJ 175572 Based on interview, record review and review of facility documents, it was determined that the facility failed to ensure that a resident who did not have a Pressure Ulcer (PU) upon admission and who was identified at risk of developing a PU, received care and services in accordance with professional standards of practice to prevent PUs. Resident # 147 developed a facility aquired Stage 3 left hip PU that was identified during an outpatient (outside) wound care physician visit/consult on 5/22/24. This deficient practice was identified for 1 of 1 resident (Resident #147) reviewed for wound care and was evidenced by the following: The surveyor reviewed the closed Medical Record (MR) for Resident #147. According to the admission Record, Resident #147 was admitted to the facility with diagnoses which included but were not limited to; [...]

Inspectors wroteBased on observation, interview and document review it was determined that the facility failed to store food in a sanitary manner, and maintain the kitchen equipment and environment in a clean and sanitary manner to prevent contamination from foreign substances and the potential for the development of food borne illness. This deficient practice affected all residents who resided at the facility, and was evidenced by the following: On 6/16/25 at 8:17 AM, the surveyor conducted an initial tour of the kitchen in the presence of the Assistant Director of Dining (ADD) and observed the following: 1. The white ceiling tiles in the food preparation area had visible debris affixed to the tiles and dust like debris on the ceiling vents. The ADD stated, I can see it. 2. [...]

Inspectors wroteBased on observation, interview, and document review, it was determined that the facility failed to follow appropriate hand hygiene during the meal service to prevent the spread of potential infection, and failed to ensure their Water Safety Management program included a process to prevent the potential transmission of Legionella (a bacteria found in contaminated water that causes a severe lung infection). This deficient practice had the potential to effect all residents who resided at the facility and was evidenced by the following: a) Surveyor #1 On 6/16/25 at 12:09 PM, the surveyor observed a Certified Nurse Aide (CNA) deliver the lunch tray to a resident in room [ROOM NUMBER] and then exited the resident's room without performing hand hygiene (HH). [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure that all residents had their call light (a button used to contact staff) within easy reach and accessible at all times. while in their room. This deficient practice was identified for 7 of 15 resident's reviewed (Resident #12, #15, #19, #21, #22, #25 and #31) and was evidenced by the following: 1) On 6/16/25 at 8:30 AM, Surveyor #1 observed Resident #15 in bed, the call light was observed on the floor. Surveyor #1 observed that the call bell light was not within the resident's reach. On 6/18/25 at 8:10 AM, Surveyor #1 entered Resident #15's room. The resident reported pain to the right hip, and Surveyor #1 asked the resident to activate the call light to contact the staff. The resident stated, I cannot see the call light. [...]

Inspectors wroteBased on interviews, and review of pertinent facility documentation on 6/16/25 and 6/19/25, it was determined that the facility failed to report falls that resulted in injury and required hospitalization to the New Jersey Department of Health (NJDOH) as required, and report injuries of unknown origin within 2 hours for 3 of 3 residents reviewed for injury of unknown origin, (Resident #15, #25 and #44). The deficient practice was evidenced by the following: Refer to F610 1. According to the facility admission Face Sheet (an admission summary), Resident #15 was admitted to the facility with diagnoses which included but not limited to; Hypertension, difficulty in walking, history of falls, unspecified abnormality of gait and mobility and vascular dementia. [...]

Inspectors wroteComplaint #: NJ 175572 Based on interview, record review and review of pertinent documents it was determined that the facility failed to ensure thorough investigations were conducted to ensure abuse or neglect had not occurred for a) a resident who was identified as having a new stage 3 wound that was identified during an outpatient (outside) physician visit conducted on 5/22/24 (Resident # 147), b) when a severely cognitively impaired resident was found laying on the floor in a pool of blood, from an unwitnessed fall that resulted in a head injury and required emergent transfer to the hospital on 6/2/25 (Resident #25), c.) Resident #44) who sustained an unwitnessed fall in the bathroom, and blood was also identified at the bedside on 11/4/24; and on 2/9/25 sustained another unwitnessed fall with skin tear. [...]

Inspectors wroteBased on interview and document review it was determined that the facility failed to submit the required Minimum Data Set (MDS) assessment within the appropriate timeframe for 3 of 7 system selected MDS' reviewed (Resident #4, Resident #8, and Resident #24) and was evidenced by the following: On 06/16/25 at 2:27 PM, the surveyor requested the Validation report for Resident #4, for the admission dated 7/13/22; Resident #8 for the admission dated 8/4/21; and Resident #24 for the admission dated 7/6/22. On 06/18/25 at 11:49 AM, the surveyor interviewed the Registered Nurse MDS Coordinator (MDSRN) who stated she has been employed at the facility since May, 2025. At that time, the surveyor reviewed Validation reports with the MDSRN who confirmed: - Resident #4 required a Quarterly MDS to be completed by 1/20/25, and it was completed on 2/4/25. The MDSRN stated it was completed late. [...]

Inspectors wroteBased on interview, record review and review of pertinent documents it was determined that the facility failed to ensure that accurate the medial record accurately documented the care provided to a resident who was having difficulty breathing and required transfer to the hospital. This deficient practice occurred for 1 of 1 closed resident record reviewed for hospitalization (Resident #44) and was evidenced by the following: On 06/18/25 at 1:12 PM, the surveyor completed an initial review of the electronic medical record (EMR) and reviewed an Other Change in Condition note completed by a Registered Nurse (RN) on 3/20/25 at 11:56 PM which revealed the following: Residents's condition is getting worse. [Their] cough is getting worse and very congested. Contatcted [General Practioner] to request lab work . Checked [vital signs] as follows: [...]

Inspectors wroteBased on observations, interviews and review of facility documentation it was determined that the facility failed to a.) label, date, and store potentially hazardous foods appropriately to prevent food borne illness; b.) maintain kitchen equipment in a manner to prevent microbial growth, and c.) maintain multiuse food-contact surface cutting board in a manner to prevent microbial growth. This deficient practice was evidenced by the following: On 1/30/24 at 9:54 AM, the surveyor, in the presence of a second surveyor and the Director of Dining services (DDS) toured the kitchen, and observed the following: In walk-in freezer #1: 1. A 22-quart plastic food storage container containing, what was identified by the DDS as, rice soup. The container was not labeled or dated. At this time the DDS stated, that should have been labeled. 2. [...]

Inspectors wroteBased on observation, interview, record review, as well as a review of pertinent facility documents, it was determined that the facility failed to ensure that a resident was transferred using the correct mechanical lift device and utilized the sufficient required staff assistance to prevent accidents and injury for 1 of 3 residents reviewed; (Resident #14). On 6/23/21, Resident #14 was improperly transferred by 1 staff instead of 2, which resulted in significant bruising on the left axillary region, a left chest wall hematoma (a collection of blood outside of the vessels caused by an injury to the wall of the blood vessel, prompting blood to seep out of the vessel into the surrounding tissues) and complaints of pain that resulted in emergency room services and hospitalization. This deficient practice was evidenced by the following: [...]

Inspectors wroteBased on interview and record review it was determined that the facility failed to report three injuries of unknown origin to the New Jersey Department of Health (NJDOH) for 1 of 3 residents reviewed for accident and incidents (Resident #14). This deficient practice was evidenced by the following: On 9/01/21 at 10:11 AM, the surveyor observed Resident #14 seated in a wheelchair at the bedside. The resident had a fabric transfer sling (a device that is used in conjunction with a mechanical lift to transfer a patient between various surfaces such as a bed to chair) placed beneath his/her back and lower body in the wheelchair. The resident was very hard of hearing and was unable to be interviewed. According to Resident #14's Face Sheet (an admission summary), the resident was initially admitted to the facility in 11/2016 and had diagnoses which included but were not limited to: [...]

Inspectors wroteBased on observation, interview and review of facility documentation it was determined that the facility failed to: a) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses; and, b) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination. This deficient practice was observed and evidenced by the following: On 8/31/21 from 9:42 AM until 10:46 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD) and observed the following: 1. In the freezer there was one 18.75 pound unsealed, opened box of cinnamon roll dough with the inner clear plastic bag opened with the rolls visible and exposed to air and no opened date. [...]

Inspectors wroteBased on interview and record review it was determined that the facility failed to complete a thorough investigation related to an injury of unknown origin for 1 of 3 residents reviewed for accidents and incidents, (Resident #14). This deficient practice was identified by the following: On 9/01/21 at 10:11 AM, the surveyor observed Resident #14 seated in a wheelchair at the bedside. The resident had a fabric transfer sling (a device that is used in conjunction with a mechanical lift to transfer a patient between various surfaces such as a bed to chair) placed beneath his/her back and lower body in the wheelchair. The resident was very hard of hearing and was unable to be interviewed. According to Resident #14's Face Sheet (an admission summary) the resident was initially admitted to the facility in 11/2016 and had diagnoses which included but were not limited to: [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to maintain infection control standards and procedures to address the risk of infection transmission by failing to perform a wound treatment in a safe and sanitary manner for 1 of 1 nurse observed providing a wound care treatment to 1 of 1 resident, (Resident #2). This deficient practice was evidenced by the following: On 8/31/21 at 11:39 AM, the surveyor observed Resident #2, nonverbal, seated in a recliner chair in his/her room, with a dressing to the left elbow and left wrist. According to the Face Sheet, Resident #2 was admitted to the facility in 09/2019 with diagnoses that included but were not limited to: [...]