Stonebridge Health & Rehabilitation Center

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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]). [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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).

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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).