Stonebridge Health Rehab

Inspectors wroteBased on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program to the maximum extent practicable to avoid duplicative testing and effort, which included incorporating the recommendations from the Preadmission Screening and Resident Review level II determination and the Pre-admission Screening and Resident Review evaluation report into a resident's assessment, care planning and transitions of care for one (Resident #1) of six residents reviewed for PASARR assessments. The facility failed to submit the Medicaid recertification in a timely manner resulting in Resident # 1's loss of eligibility for PASRR services. This failure could place residents at risk of not receiving services that would enhance his or her quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 8 residents (Resident #16 reviewed for pain. The facility failed to ensure Resident #16 received pain management to the fullest extent possible, resulting in her experiencing pain on 04/22/2026. This failure placed residents at risk of uncontrolled pain.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 3 residents (Resident #36) reviewed for medication errors. 1. The facility failed to administer the correct dosage of medication to Resident #36 on 04/22/26. 2. The facility failed to administer the medication to Resident #36 at the time ordered by Physician 04/22/26. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, worsening or exacerbation of chronic medical conditions, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 1 of 1 resident (Resident #22) observed for infection prevention. 1. The facility failed to ensure CNA H was following the infection control procedures during peri-care when CNA H cleaned Resident #22's anal area first before cleaning his scrotum. 2. The facility failed to ensure CNA H and CNA I were following the infection control procedures when the same wipe was folded multiple times and used for multiple strokes while providing peri-care to Resident #22. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to assist a resident in making transportation arrangements to an outside provider for one (Resident #1) of seven residents interviewed for transportation services. The facility failed to ensure Resident #1 received transportation to his scheduled medical appointment after being provided with adequate notice. This failure could lead to the worsening of acute or chronic health conditions and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 5 (Resident #195) residents reviewed for pain. The facility failed to provide scheduled Morphine and Tramadol for Resident #195 from 02/07/2025-02/09/2025 which resulted in mental anguish and untreated pain. An IJ was identified on 02/11/2025. The IJ template was provided to the facility on [DATE] at 04:56 PM. While the IJ was removed on 02/14/2025, the facility remained out of compliance at a scope of isolated and a severity level of 1 because all nursing staff had not been trained on pain assessments and the facility's need to evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The cook was not wearing hair restraints while in the kitchen. The cook did not practice appropriate hand washing prior to preparing and cooking food. The cook did not wash hands or wear gloves when moving from one operation to another. The DA did not wash hands or wear gloves when moving from one operation to another. Non-dietary staff, CNA entered the kitchen without hair restraint. Non-dietary staff did not wash hands. The DM improperly cleaned the thermometer while checking holding temperatures of foods prior to meal service. The DM did not have knowledge of cleaning and sanitization of the thermometer. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 of 1 medication storage room and 2 of 3 medication carts. A) The facility failed to ensure expired supplies and medications were removed from the medication storage room. B) The facility failed to ensure expired supplies and medications were removed from the nurses' medication cart for 400 hall. C) The facility failed to ensure that the nurses medication cart for 100 hall was secured by a lock when it was left unattended by LVN A. These failures could place residents at risk of contamination causing illness, decreased effectiveness of medication, and risk of injury to other residents if medication left unsecured were consumed.

Inspectors wroteBased on observation, interview, and record review the facility failed to prepare foods by methods that conserve nutritive value, flavor, and appearance in the facility's only kitchen. The DM prepared food 2 1/2 hours prior to meal service. The DM held food in a convection steamer and/or on a hot food table for more than 2 1/2 hours prior to meal service. Food service started 150 minutes after food was placed on the steam table. Food item not being pureed with adequate and appropriate liquids. Pureed foods were prepared with water. Liquids for pureed foods were not measured. Thickener for pureed foods was not measured. Pureed and mechanical soft foods did not follow policy/procedures of determining number of servings needed to determine the portion size method. Condiments and seasonings used on regular textured foods was not used on puree and mechanical soft foods. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the residents' right to privacy during personal care for 1 of 2 residents (Resident #5) reviewed for privacy. The facility failed to ensure RN G provided and continued to provide privacy during wound care for Resident #5, by ensuring the door and privacy curtain remained closed throughout the procedure. This failure could place residents at risk of having their bodies exposed to the public, resulting in low self-esteem and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 1 of 4 (Resident #22) reviewed for quality of care. The facility failed to ensure Resident #22 received adequate physical assessment, including vital signs and lung sounds, prior to and after she received medications through a nebulizer and while on antibiotics for an upper respiratory infection. The failure could place resident at an increased risk for an adverse reaction to medication.

Inspectors wroteBased on observations, interviews, and record reviews 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 1 of 5 residents (Resident #5) reviewed for infection control. 1. The facility failed to ensure RN G and CNA H followed enhanced barrier precautions when they provided wound care for Resident #5 on 02/13/2025. 2. The facility failed to ensure RN G followed infection control precautions when she performed wound care on Resident #5. These failures could place residents at risk for cross contamination and infection.

Inspectors wroteBased on interview and record review the facility failed to establish an infection prevention and control program (ICPC) that included, at a minimum, an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for 1 of 5 resident (Resident #22) reviewed for antibiotic stewardship program. The facility failed to follow antibiotic stewardship policy for Resident #22 by not ensuring an infection surveillance was performed per facility policy. This deficient practice could place residents at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased multi drug resistant organisms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store and label biologicals for one (Resident #1) of five residents reviewed for improper medication storage, in that: The facility failed to remove Resident #1's narcotics (Hydrocodone) from the medication cart when it was discontinued July of 2023 which resulted in a medication diversion on 03/09/24. This noncompliance was identified as PNC. The deficient practice began on 03/09/24 and ended on 03/12/24. The facility had corrected the noncompliance before the survey began. This failure could place residents whose narcotics have been discontinued at risk of receiving discharged discontinued medication, medication errors, and drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for 1 of 1 (Resident #1) residents reviewed for discharge rights. The facility failed to document in Resident #1's chart actions made to ensure a safe and orderly discharge, and to find alternate placement for Resident #1. This failure placed residents at risk of being improperly discharged .

Inspectors wroteBased on interview and record review, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for 1 of 1 (Resident #1) residents reviewed for discharge rights. The facility failed to provide their bed hold policy to Resident #1 or her RP, in writing, upon Resident #1's discharge from the facility on 1/03/2024. This failure placed residents at risk of being improperly discharged .

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all residents had a right to be treated with respect and dignity for three of eight (Resident #3, Resident #46, and Resident #158) residents reviewed for dignity. The facility failed to ensure Resident #3, Resident #46 and Resident #158 were not referred to as feeders. This failure placed residents at risk of not being treated with dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for 5 of 8 (Resident #35, Resident #55, Resident #52, Resident #27 and Resident #108) residents reviewed for activities of daily living. 1. The facility failed to ensure Resident #35 received regular showers or baths. 2. The facility failed to ensure Resident #55 and Resident #52 received nail care. 3. The facility failed to ensure Resident #27 and Resident #108 received a shave. These failures placed residents at risk of not receiving help with activities of daily living.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals were stored in locked compartments and inaccessible to unauthorized staff, visitors, and residents for 3 (100, 300, and 400 hallway medication cart) of 5 medication carts reviewed for medication storage. LVN E failed to ensure that the Medication Cart for the 100 Hallway was not left unattended and unlocked. RN A failed to ensure that the Medication Cart for the secured 300 Hallway was not left unattended and unlocked. MA F failed to ensure that the Medication Cart for the 400 Hallway was not left unattended and unlocked. These failures could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed and over-the-counter medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that meets a resident's medical, nursing, mental, and psychosocial needs for two of two residents (Resident #55 and Resident #33) reviewed for pressure ulcers. 1. Resident #55 had three wounds which did not appear on the most recent comprehensive are plan last revised on 12/05/2023. 2. Resident #33 had a right buttock Stage II Pressure Ulcer (partial thickness skin and underlying tissue loss) which was not included in the comprehensive Care Plan revised on 12/20/2023. These failures could place residents at risk for pain from the wound, pain from any debridement procedures (sharp instrument or chemical excision of dead tissue often used to promote healing of pressure ulcers) and pain from the wound care required to promote healing. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a sanitary environment to help prevent the transmission of communicable diseases and infections for three of seven residents (Resident #7, Resident #12, and Resident #14) observed while receiving direct resident care by facility staff. The facility failed to disinfect a wrist blood pressure cuff and a Hoyer lift (a manual or electronic metal frame with wheels and a sling-fastening device that is used to lift residents out of bed or a chair to be transferred to another bed or chair) before and after use on Resident #7. Failure to disinfect reusable resident-care items could affect all residents who required a blood pressure check or required use of a transfer assistive device, in the form of a Hoyer lift, by promoting the spread of potential pathogens contained on those items. [...]