Stonebridge Hermann

Inspectors wroteBased on interview and record review, the facility staff failed to post accurate nurse staffing information, which included the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care per shift when staff included another employee from the assisted living facility to the total number of nursing staff working. The census was 70. 1. Review of the facility policies showed staff did not provide a policy for nurse staff posting. Review of the nurse staff posting sheets, dated 03/01/26 to 05/31/26, showed sheets contained the total number of licensed and unlicensed staff who provided care to both the skilled nursing facility and the attached assisted living facility. The census on the staff posting sheets reflected the number of residents in the Skilled Nursing facility. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD- a serious type of pneumonia (lung infection) caused by Legionella bacteria, which places all residents of the facility at risk of exposure which could lead to illness. Facility staff failed to implement an enhanced barrier precautions (EBP) system for one (Resident #33) of two sampled residents with wounds when facility staff failed to wear appropriate personal protective equipment (PPE) during high-contact care activities and place PPE in close proximity. The facility census was 56. 1. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to ensure six Nurse Aide's ((NA) NA A, NA B, NA C, NA D, NA E, and NA F) of eight completed the nurse aide training program within four months of his/her employment in the facility. The census was 56. 1. Review of the facility's policies showed the facility did not provide a policy for NA qualifications. 2. Review of NA D's personnel file showed a hire date of 04/06/22. Review showed the NA file did not contain documentation the NA completed the required nurse aide training program. During an interview on 09/17/24 at 1:04 P.M., the administrator said this employee is 96% done with his/her classes. He/She said he/she is behind because he/she tried out another unit for three and half weeks before returning to nursing care. 3. Review of NA F's personnel file showed a hire date of 06/12/23. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to maintain a safe, clean, comfortable and homelike environment, when staff failed to maintain resident equipment and rooms in good repair for five residents (Resident #20, #23, #41, #50 and #57). The facility census was 62. 1. Review of the facility's policy titled, Safe and Homelike Environment, dated October 2017, showed staff were directed to do the following: -In accordance with resident's rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible; -The facility will maintain a clean environment; -The facility will provide and maintain bed and bath linens that are clean and in good condition; -Report any furniture in disrepair to Maintenance promptly; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to review and revise the plan of care for three residents (Resident #22, #23, and #41). The facility census was 62. 1. Review of the facility's policy titled, Comprehensive Care Plans, dated September 2022, showed staff were directed to do the following: -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 process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure three residents (Residents #23, #35 and #50), who were unable to complete their own activities of daily living (ADLs) (showering/bathing, dressing, and personal hygiene), received the necessary care and services to maintain good personal hygiene. The facility census was 62. 1. Review of the facility's policy titled, Activities of Daily Living (ADLs), Supporting, dated March 2018, showed staff were directed to do the following: -Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs; -Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to transfer two residents (Resident #22 and #20) in a safe manner, and failed to properly propel two residents (Resident #15 and #48) in wheelchairs in a manner to prevent accidents. The facility census was 62. 1. Review of the facility's policy titled, Safety and Supervision of Residents, dated July 2017, showed staff were directed to do the following: -Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents; -The care team shall target interventions to reduce individual risks related to hazards in the environment, including inadequate supervision and assistive devices; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to remove soiled gloves and/or properly wash hands and provide an environment to prevent the spread of bacteria and other infection causing contaminants during the provision of wound care for one resident (Residents #1). Additionally staff failed to remove soiled gloves and/or properly wash hands during incontinence care for one resident (Resident #22). The facility census was 62. 1. Review of the facility's policy titled, Wound Care, dated October 2018, showed staff were directed to do the following: -Use disposable cloth (paper towel is adequate) to establish clean field on resident's over bed table. Place all items to be used during procedure on the clean field; -Dress wound. Pick up sponge with paper and apply directly to area. [NAME] tape with initials, time, and date and apply to dressing. [...]

Inspectors wroteBased on interview and record review, facility staff failed to develop and implement a comprehensive person-centered care plan for two residents (Resident #4, and #50). The facility census was 62. 1. Review of the facility's policy titled, Comprehensive Care Plans, dated September 2022, showed staff were directed to do the following: -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 timeframe's 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, and will incorporate the resident's personal and cultural preferences in developing goals of care. [...]