Stonebridge Marble Hill

Inspectors wroteBased on interview and record review, the facility failed to ensure informed consent was obtained and documented for the use of psychotropic (a medication that affects brain activities associated with mental processes and behavior) medications for three residents (Residents #8, #10, and #61) out of six sampled residents. This failure prevented the resident and/or their representative from knowing the risks and the benefits of using psychotropic medications. The facility census was 71. Review of the facility's policy titled, Psychotropic Medication Use, revised October 2017, showed: - Psychotropic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review; [...]

Inspectors wroteBased on interview and record review, the facility failed to attempt a gradual dose reduction (GDR) for psychotropic (medications that affect how the brain works and causes changes in mood, awareness, thoughts, feelings, or behaviors) medications for two residents (Residents #7 and #10) out of five sampled residents. The facility census was 71. Review of the facility policy titled, Psychotropic Medication Use, dated October 2017, showed: - Psychotropic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review; - The physician shall respond appropriately by changing or stopping problematic doses or medications or clearly documenting why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences. 1. Review of Resident #7's medical record showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide required written notice and documentation related to discharge and bed hold policy requirements, including the required daily bed hold rate for four residents (Residents #1, #3, #13, and #70) out of four sampled residents. The facility also failed to complete a recapitulation of stay upon discharge to home for one resident (Resident #72) out of two closed records reviewed. The facility census was 71. Review of facility policy titled, Bed Holds, dated March 2022, showed: - Upon admission and when a resident is transferred for hospitalization or for therapeutic leave, the facility will provide information regarding the bed hold policy to the resident or representative in a written format that is understood by the resident or the representative; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide showers for six residents (Residents #5, #7, #19, #31, #41 and #61) out of 18 sampled residents. The facility's census was 71. Review of facility policy titled, Bath, Shower/Tub, dated February 2018, showed: - Staff to document the following: the date and time the shower or bath was performed; all assessment data obtained during the shower or bath; how the resident tolerated the shower or bath; and if the resident refused the shower or bath, the reason why, and the intervention taken. 1. Review of Resident #5's medical record showed: - admission date of 12/15/23; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to use proper infection control techniques during wound care for two residents (Resident #7 and #14) out of three sampled residents and during blood glucose (blood sugar) test for four residents (Residents #3, #61, #66, and #75) out of five sampled residents. The facility census was 71. Review of the facility's policy titled, Hand Hygiene, not dated, showed: - All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors; - The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to putting on gloves, and immediately after removing gloves; - Hand hygiene is indicated and will be performed: between resident contacts; [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct at least twelve hours of nurse aide in-service education per year and failed to provide the required competency of Abuse Prevention and Dementia Care (care of a resident with an impaired ability to remember, think, or make decisions). This affected one Certified Nurse Assistant (CNA) (CNA B) out of two sampled CNAs. The facility's census was 71. Review of the facility's policy titled, Required Training and Continuing Education of Nurse Aides, dated September 2022, showed:- The facility will provide at least 12 hours of in-service training annually, based on the employment date, not the calendar year;- Minimum training will include: dementia management and care of the cognitively impaired, abuse, neglect, and exploitation prevention. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow the resident's care plan, dated 8/30/24, to ensure staff utilized safe transfer techniques for one resident (Resident #1) when staff failed to transfer the resident via a mechanical lift out of one sampled resident. The resident sustained a hematoma (a collection of blood that pools outside of a blood vessel in an organ, tissue, or body space) to the chest area. The facility census was 72. The Administration was notified on 12/11/24 of the Past Non-Compliance citation. On , 12/06/24 and 12/09/24, the facility staff took appropriate corrective actions as confirmed by survey staff during the onsite visit. The facility started an investigation, and assessed Resident #1. The facility started an in-service that covered the use of care plans, policy and procedure for transfers, and proper use of a gait belt and Hoyer lift. [...]

Inspectors wroteBased on interview and record review, the facility failed to allow one resident (Resident #1) to return to the facility after being sent out to the hospital for an evaluation. The facility census was 76 residents. Review of the facility's policy titled, Bed Holds, dated March 2022, showed: - When emergency transfers are necessary, the facility will provide the resident or representative with information concerning our bed-hold policy within 24 hours of such transfer; - If the facility determines that a resident who was transferred cannot return to the facility, the facility will comply with the facility's Discharge Policy. Review of the facility's policy titled, Transfers and Discharges (Including Against Medical Advice (AMA), dated September 2022, showed: - If a Notice of Discharge is given the facility will send a copy of transfer or discharge notice to the Ombudsman. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for transfer, for seven residents (Resident #8, #21, #31, #33, #35, #36, and #55) out of 10 sampled residents. The facility's census was 82. The facility did not provide a policy for transfer/discharge notification. 1. Review of Resident #8's medical record showed: - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of their bed hold policy at the time of transfer to the hospital for five residents (Resident #21, #31, #33, #36, and #55) out of 10 sampled residents. Facility census was 82. Review of the facility's policy titled, Bed Holds, dated March 2022, showed: - Upon admission and when a resident is transferred to hospitalization or for therapeutic leave, the facility will provide information regarding the bed-hold policy to the resident or representative in a written format that is understood by the resident or representative; - When emergency transfers are necessary, the facility will provide the resident or representative with information concerning the bed-hold policy within 24 hours of such transfer. 1. Review of Resident #21's medical record showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement comprehensive care plans for two residents (Resident #33 and #35) out of 18 sampled residents. The facility's census was 82. Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, dated October 2017, showed: - The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; - The care planning process will facilitate resident and/or representative involvement, include an assessment of the resident's strengths and needs, and incorporate the resident's personal and cultural preferences in developing the goals of care; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have an order for and a process in place for accessing, maintaining, and assessing a mediport (medical device put just below skin for access if blood needs drawn or intravenous medications need given) for one resident (Resident #35) out of one sampled resident. The facility did not provide a policy on mediport care/maintenance. 1. Review of Resident #35's medical record showed: - A computed tomography (CT - a medical imaging scan used to obtain detailed internal images of the body) scan report, dated 06/02/22, showed a right-sided mediport catheter; - No order for the mediport; - No orders and/or protocols to access and maintain the mediport; - No documentation for assessments of the mediport. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of five percent (%) or less. There were six errors out of 43 opportunities for errors, resulting in an error rate of 13.95%. This affected six residents (Resident #17, #20, #24, #33, #44 and #46), out of 10 sampled residents. The facility census was 82. The facility did not provide a policy for insulin pens. Review of Novolog (a rapid acting insulin injected just below the skin that helps lower mealtime blood sugar spikes) Flex Pen (insulin in a pen-type device) manufacturer instructions, revised February 2023, showed: - Before each injection small amounts of air may collect in the cartridge during normal use, to avoid injecting air and to ensure proper dosing: remove the cap; attach the needle; prime the pen by turning the dose selector to select two units; [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an Infection Prevention and Control Program (IPCP) that included an antibiotic stewardship program. This deficient practice had the potential to affect all residents in the facility. The facility census was 82. Review of the facility's policy titled, Infection Prevention and Control Program, dated 2018, showed: - The facility's Infection Prevention and Control Program (IPCP) follows national standards and guidelines to prevent, recognize and control the onset and spread of infection whenever possible; - The Infection Prevention and Control Program includes an antibiotic stewardship program. [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure all residents were kept free from possible accident hazards when the facility staff failed to monitor one resident (Resident #12) outside the sample for self administration of dietary supplements bought on the Internet and for giving the same supplements to another resident (Resident #49) out of a sample of 18. The facility census was 73. Record review of the facility policy titled Medications Brought to the Facility by the Resident/Family, revised April 2007, showed: -The facility shall ordinarily not permit residents and families to bring medications into the facility; -Residents and families must report to the nursing staff any medications that they want to bring, or have brought into the facility; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to utilize proper technique during incontinent care for one resident (Resident #3) when staff touched the trash can during care and dropped the box of wipes on the floor three times. Staff did not change gloves, perform hand hygiene after touching the trash can and the box of wipes that he/she picked up from the floor. During wound care staff failed to use a barrier for supplies, disinfect the bandage scissors, used for multiple residents, before and after use, and perform appropriate hand hygiene and glove changes for one resident (Resident #14), outside of 18 sampled residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide documentation of ongoing assessments, monitoring, and communication between the facility and the dialysis (a process for removing waste and excess water from the blood) center for one resident (Resident #7) out of 18 sampled residents and two residents (Resident #31 and #32) outside of the sample. The facility's census was 73. Record review of the facility's policy, End-Stage Renal Disease, Care of a Resident With revised September 2010, showed: - Agreements between this facility and the contracted end stage renal disease facility (ESRD) include all aspects of how the resident's care will be managed including: a) How the care plan will be developed and implemented; b) How information will be exchanged between the facilities. 1. Review of Resident #7's medical record showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician responded to the pharmacist's recommendations in regard to the resident's antidepressant medications for two residents (Resident #14 and #22) out of 18 sampled residents. The facility's census was 73. Record review of the facility's policy titled, Gradual Dose Reduction of Psychotropic Drugs, updated September 2022, showed: - Reducing the need for and maximizing the effectiveness of medications shall be considered for all residents who use psychotropic drugs; - GDR's will be documented on the psychotropic Dose Reduction History form; [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to label and store drugs in accordance with currently accepted professional principles and had potential to affect all residents. The facility's census was 73. Review of the facility's policy titled, Storage of Medications, last revised April 2007, showed: - Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers; - The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner; - Medications requiring refrigeration must be stored in a refrigerator located in the drug room at nurse's station or other secure location. Medications must be stored separately from food and must be labeled accordingly. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the quality assessment and assurance (QAA) committee attendees included an Infection Preventionist (IP). This failure had the potential to affect all 73 residents who reside at the facility. The facility's census was 73. Record review of the QAA Committee Members did not show the Infection Preventionist as a committee member. Record review of the QAA committee attendance records, dated July 2022 through December 2022, provided by the facility, showed the Infection Preventionist did not attend the meetings as required. During an interview on 2/9/23 at 5:35 P.M., the Administrator said their Infection Preventionist is new and recently certified. She said the Infection Preventionist needs to be put on the list. She said the previous IP attended meetings. [...]