Stonebridge Desoto

Inspectors wroteBased on interview and record review, the facility failed to provide written notice of transfer to the resident and/or the resident's representative that included all required transfer information, including bed-hold information for six residents (Residents #3, #10, #16, #34, #36 and #40) out of six sampled residents who were transferred to the hospital. The facility census was 49. Review of the facility's policy titled, Bed Holds, dated March 2022, showed: The facility would inform residents upon admission and prior to a transfer for hospitalization or therapeutic leave of the bed-hold policy; Upon admission and when a resident transferred for hospitalization or therapeutic leave, the facility would provide written information regarding the bed-hold policy to the resident or representative in a format they could understand; [...]

Inspectors wroteBased on interview and record review, the facility failed to complete comprehensive Minimum Data Set (MDS, a federally mandated assessment completed by the facility) assessments within the required timeframes for two residents (Residents #22 and #55) out of 13 sampled residents. The facility census was 49. Review of the facility's policy titled MDS-Staff Responsibilities, dated October 2017, showed: - Members of the interdisciplinary team (IDT) would complete assigned sections of the MDS and corresponding Care Area Assessments (CAAs) within the timeframes established by the Resident Assessment Instrument (RAI) Manual; - The MDS Coordinator would schedule admission, quarterly, and annual MDS assessments; - The MDS Department would immediately notify the Administrator of issues affecting timely completion of MDS assessments. 1. Review of Resident #22's medical record showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a baseline care plan (the minimum healthcare information necessary to properly care for the immediate needs of a resident) for three residents (Residents #22, #43, and #55) out of four sampled residents. The facility census was 49. The facility did not provide a policy regarding Baseline Care Plans. 1. Review of Resident #22's medical record showed: - admission date of 06/01/26; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders for daily weights for one resident (Resident #10) out of three sampled residents. The facility census was 49. Review of the facility policy titled, Policy and Procedure Physician Orders, revised 01/04/23, showed:- Clear and complete orders will be transcribed to the appropriate administration record of either the Medication Administration Record (MAR) or the Treatment Administration Record (TAR);- New orders will be reviewed at least weekly by the Interdisciplinary Team as a part of routine clinical review;- A monthly review of physician orders will be completed to assure appropriateness, accuracy, and completeness. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement physician orders for pre- and post-dialysis assessments and pre- and post-dialysis weights and failed to develop a comprehensive care plan that addressed the resident's dialysis needs for one resident (Resident #55) out of one sampled resident receiving dialysis. The facility census was 49. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than five percent during medication administration. There were 27 opportunities for error and three medication administration errors, resulting in an error rate of 11.11%, which affected two residents (Residents #16 and #26) out of 11 sampled residents. The facility census was 49. The facility did not provide a policy regarding priming insulin pens prior to administration. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the dietary department during the storage and preparation of food, increasing the potential for cross-contamination and food-borne illness. This deficient practice had the potential to affect all residents who received meals prepared by the facility. The facility census was 49. Review of the facility's policy titled, Sanitization, dated October 2008, showed:- Kitchens, kitchen areas, and dining areas would be kept clean and free of litter and debris;- Utensils, counters, shelves, and equipment would be maintained in good repair and kept free of breaks, corrosion, open seams, cracks, and chipped surfaces that could interfere with proper cleaning;- Kitchen and dining room surfaces not in direct contact with food would be cleaned routinely to prevent the accumulation of dirt and grime; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the safety of one resident (Resident #1) out of three sampled residents when staff failed to place a fall mat next to the resident's bed as directed by the care plan. The resident fell out of bed onto the floor resulting in injury. The facility census was 52. The administration was notified on 07/24/25 of the Past Non-Compliance which occurred on 07/18/25. On 07/18/25, upon notification, the facility administration started an investigation and notified the Department of Health and Senior Services of the fall which resulted in a fracture. The non-compliance was corrected on 07/18/25, as the facility in-serviced all staff on the facility's policy and procedures on Falls and Fall Risk, Managing, High Fall Risk Patient Interventions, and on the Abuse and Neglect Policy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a physician's order for bilevel positive airway pressure (BIPAP - a noninvasive ventilation device that helps people breathe by delivering pressurized air into the airways) included settings. This affected one resident (Resident #32) out of one sampled resident. The facility's census was 46. Review of the facility's policy titled, CPAP/BiPAP Support, dated March 2015, showed: - Review the physician's order to determine the oxygen concentration and flow, and the PEEP pressure for the machine. Review of Resident #32's medical record showed: - admission date of 12/06/22; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This had the potential to affect all residents. The facility's census was 46. Review of the facility's policy titled, Sanitization, dated October 2008, showed: - The food service area shall be maintained in a clean and sanitary manner; - All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects; - All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, and cracks, and chipped areas that may affect their use or proper cleaning. Seals, hinges, and fasteners will be kept in good repair; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain appropriate infection control practices by not following enhanced barrier precautions (EBP) for one resident (Resident #20) out of three sampled residents and by not performing proper hand hygiene and glove changing techniques during incontinent care, transfer, and wound care for three residents (Resident #20, #22 and #23) out of 16 sampled residents. The facility's census was 46. Review of the facility's policy titled Enhanced Barrier Precautions, last updated 04/04/24, showed: - All staff receive training on enhanced barrier precautions upon hire and at least annually and expected to comply with all designated precautions; - All staff receive training on high-risk activities and common organisms that require enhanced barrier precautions; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide access to survey results. This had the potential to affect all residents. The facility census is 46. Review of the facility's policy titled, Examination of Survey Results, dated April 2007, showed: - A copy of the most recent standard survey along with state approved plans of correction of noted deficiencies, is maintained in a three-ring binder located in an area frequented by most residents, such as the main lobby or resident activity room. Observations from 03/10/25 through 03/13/25 showed: - On 03/10/25 at 11:35 A.M., no survey binder was found at the nurses' station or activities room; - On 03/13/25 at 2:15 P.M., no survey binder was found at the nurses' station or activities room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices affected all residents. The facility census was 46. Review of the facility's Food Receiving and Storage policy, revised July 2014, showed: - Foods shall be received and stored in a manner that complies with safe food handling practices; - All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). 1. Observation on 02/06/24 at 10:46 A.M. of the reach-in cooler showed: - One large container of Ott's Famous dressing with no opened date and no expiration date; - One large container of ranch dressing, labeled as Italian dressing, with no opened date and no expiration date; - One large container of maraschino cherries with no opened date. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a facility-initiated transfer when one resident (Resident #44) out of one sampled resident transferred to the hospital. The facility's census was 46. 1. Review of Resident #44's medical record showed: - Resident transferred to the hospital for medical evaluation on 01/31/24 and readmitted to the facility on [DATE]; - No documentation of written notification to the resident and/or the resident's representative of the resident's transfer to the hospital on [DATE]. During an interview on 02/09/24 at 12:15 P.M., the Administrator said she would expect the resident and/or the resident's representative to receive a transfer notification in writing when a resident is transferred to the hospital. The facility did not provide a policy regarding transfers.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of the facility's bed hold policy when one resident (Resident #44) out of one sampled resident transferred to the hospital. The facility's census was 46. Review of the facility's policy, Bed Hold Notice Prior to Transfer, revised October 2017, showed: - In the event of a resident transfer to the hospital or the resident goes on therapeutic leave, the facility will provide written information to the resident and/or the resident representative regarding the bed hold; - The notice will be provided prior to leave, if possible. In the event the notice is not provided prior to leave due to unforeseen circumstances, the notice will be provided within the requirements for such notice; - Attempts at delivery of the bed hold notice will be documented; [...]

Inspectors wroteBased on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS, a federally mandated assessment completed by the facility) assessment for two residents (Resident #11 and Resident #26) out of 12 sampled residents. The facility census was 46. Review of the facility's Certifying Accuracy of the Resident Assessment Policy showed: - All personnel who complete any portion of the Resident Assessment (MDS) must sign and certify the accuracy of that portion of the assessment; - Any individual who willfully and knowingly certifies (or causes another individual to certify) a material and false statement in a resident assessment is subject to disciplinary action and such incident must be promptly reported to the Administrator. 1. Review of Resident #11's medical record showed: - admission date of 09/07/2022; [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan to meet the individual needs for one resident (Resident #11) out of 12 sampled residents. The facility census was 46. Review of the facility's Life Enrichment Policy Program Policy, dated October 2017, showed: - Each resident's interests and needs will be assessed on a routine basis. Included in this assessment will be Minimum Data Set (MDS - a mandatory assessment completed by the facility) and Care Plan; - Activities will be designed with the intent to enhance the resident's sense of well being; promote or enhance emotional health; promote self esteem, dignity, pleasure, comfort, education, creativity, success and independence; - Space and equipment necessary are provided to ensure the resident's care plan is followed; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to update and revise a comprehensive care plan to meet the individual needs for one resident (Resident #11) out of 12 sampled residents. The facility census was 46. Review of the facility's Comprehensive Care Plans Policy, dated September 2022, showed: - It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment; - The care planning process will include an assessment of the resident's strengths and needs; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide resident care for activities of daily living (ADLs) when residents did not receive scheduled showers and preferences were not acknowledged for three residents (Resident #10, #30, and #46) out of 12 sampled residents. The facility census was 46. The facility's policy did not address shower frequency. 1. Review of Resident #10's medical record showed: - admission date of 04/25/23; - Diagnoses of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in activities, causing significant impairment in daily life), mild cognitive impairment, lack of coordination, unsteadiness on feet, weakness, high blood pressure, and heart failure. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure residents with limited range of motion (ROM) received appropriate treatment and services to increase their ROM and/or prevent a further decrease in their ROM. The facility staff failed to perform restorative services as ordered for two residents (Resident #3 and #11) out of two sampled residents. The facility census was 46. Review of the facility's Restorative Nursing Services Policy Statement, dated July 2017, showed: - Residents will receive restorative nursing care as needed to help promote optimal safety and independence; - Restorative goals and objectives are individualized and resident centered and are outlined in the resident's plan of care; - The resident or representative will be included in determining goals and the plan of care. 1. Review of Resident #3's medical record showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain orders for continuous positive airway pressure machine (CPAP - a machine that uses mild air pressure to keep breathing airways open while you sleep) settings and tubing changes for one resident (Resident #31) out of one sampled resident with a CPAP and failed to obtain a physician's order prior to oxygen use and orders for nasal cannula (a small, flexible tube that contains two open prongs that sits in the nostrils and attaches to an oxygen source) and humidifier (used to increase the moisture level) changes for one resident (Resident #100) out of one sampled resident with oxygen. The facility census was 46. Review of the facility's policy, Oxygen Administration, revised October 2010, showed: - Verify that there is a physician's order for this procedure. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to label and store medications in a safe and effective manner. This had the potential to affect all residents. The facility census was 46. Review of the facility's policy titled, Storage of Medications, dated April 2007, showed: - Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing; - The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed; - Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications must be stored separately from food and must be labeled accordingly. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain quarterly Quality Assurance & Performance Improvement (QAPI) meetings with the required members. The facility census was 46. Review of the facility's QAPI Plan, dated September 2022, showed: - The QAPI committee will meet at least quarterly and as needed; - The committee will be made up of, at a minimum, the Director of Nursing (DON), the Medical Director or designee, Administrator, and at least three other members of the facility staff. 1. Review of QAPI Meeting information, dated 01/04/24 and provided by the Administrator, showed no record of Director of Nursing (DON) or Infection Preventionist (IP) attending meeting. 2. Review of QAPI Meeting information, dated 12/27/23 and provided by the Administrator, showed no record of the Medical Director or IP attending meeting. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the prevention of communicable disease in regards to Tuberculosis (TB - a communicable disease that affects the lungs characterized by fever, cough and difficulty breathing) by not completing the admission TB screening/testing for three residents (Resident #32, #44, and #46) out of five sampled residents and failed to use proper hand hygiene during care of four residents (Resident #16, #17, #32, and #100) out of 12 sampled residents and two residents outside the sample (Resident #4 and #24). The census was 46. 1. Review of the facility's Screening Residents for TB policy, revised December 2016, showed: - The facility shall screen all residents for tuberculosis infection and disease; [...]

Inspectors wroteBased on interview and record review, the facility failed to designate a qualified individual as the Infection Preventionist (IP) for the facility's infection prevention control program. The facility census was 46. The facility did not provide a policy regarding required specialized training for the IP. Review of the prior certifications and employment record showed the prior Director of Nursing (DON) obtained certification on 10/24/23 and was no longer employed as of 12/27/23. During an interview on 02/06/24 at 3:24 P.M., the DON said she is the IP and started taking the certification classes in November or December of 2023. During an interview on 02/06/24 at 3:26 P.M., the Administrator said the DON is the IP, but she has not completed training, and there is not a back up IP.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide resident rights information on how to formally file a complaint to the Department of Health and Senior Services (DHSS) about the care they were receiving. This deficient practice had the potential to affect all residents in the facility. The facility census was 46. Review of the facility's policy titled, Resident Right Policy, dated 2017, showed: - Information about resident rights and responsibilities will be given to the resident both orally and in writing; - A posting of names, addresses, and phone numbers of all pertinent state client advocacy groups will be available in the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician's orders for one resident (Resident #1) out of three sampled residents. The facility's census was 51. Review of the facility's policy titled, Discontinued Medications, revised April 2007, showed: - A practitioner's order to discontinue a resident's medication must be documented in the resident's clinical record and on the medication administration record; - The nurse receiving the order to discontinue a medication is responsible for recording the information and notifying the dispensing pharmacy; - Discontinued medications must be destroyed or returned to the issuing pharmacy in accordance with established policies. Review of Resident #1's medical record showed: - An admission date of 08/10/23; [...]