Stonebridge Oak Tree

Inspectors wroteBased on observation, interview and record review, the facility staff failed to maintain an air gap (a safety feature which prevents sewage from backing up into ice machines) for two of two ice machine drains. This failure has the potential to affect all residents. The facility census was 34. 1. Review of the facility's policies provided showed they did not contain a policy related to ice machine air gaps. Observation on 04/29/26 during the Life Safety Code tour showed the black drain hose from the kitchen ice machine on the floor in a small puddle of water near the floor drain which did not have a cover and had an accumulation of black material. Observation also showed the white plastic drain from the dining room ice machine passed through a hole in the wall to an adjacent mechanical room and set directly on a rusted floor drain cover. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to transfer two residents (Residents #21 and #17) out of two sampled residents by mechanical lift in a manner to prevent accidents. The facility census was 34.1. Review of the facility's policy titled Lifting Machine, Using a Mechanical Lift, dated July 2017, showed the purpose of the procedure is to establish the general principle of safe lifting using a mechanical lifting device. Review showed:-At least two nursing assistants are needed to safely move a resident with a mechanical lift;-Gently support the resident as he or she is moved, but do not support any weight. Review of the Mechanical Lift operating manual, REV2.7.13.20, undated, showed there are circumstances that may require two people to safely operate the lift. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to store food in a manner to prevent contamination and out-dated use. Facility staff failed to perform hand hygiene as often as necessary, using approved techniques, to prevent cross-contamination. Facility staff failed to allow sanitized dishes to air dry prior to stacking in storage to prevent the growth of foodborne pathogens. The facility census was 30. 1. Review of the facility's Food Safety Requirements policy, dated September 2022, showed: -Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident; -Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely proper storage; [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to properly contain waste and refuse to prevent the harboring and/or feeding of rodents and pests when the facility failed ensure indoor and outdoor waste containers remained covered when not in actual use. This failure has the potential to affect all facility occupants. The facility census was 30. 1. Review of the facility's Infection Prevention and Control-Maintenance Department policy, dated 2017, showed infection prevention and control measures included waste processing systems, including dumpsters, trash bins, incinerators and et cetera. Review showed the policy directed staff to: -Enforce proper bagging and containment of waste. If inappropriately bagged items are found, notify the appropriate manager; -Maintain waste receptacles to prevent leakage; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed obtain physician orders for Continuous Positive Airway Pressure (CPAP) machines, non-invasive mechanical ventilation device, and failed to adequately clean and maintain the machines, masks and tubing for three residents (Residents #26, #9 and #14) of four sampled residents. The facility census was 30. 1. Review of the facility's policy titled CPAP/Bi-level positive airway pressure (BiPAP), non-invasive mechanical ventilation machine, Support, dated March 2015, showed staff should wipe the machine with warm soapy water and rinse at least once a week and as needed. Clean humidifier weekly and air dry. Rinse washable filter under running water once a week to remove dust and debris. Replace disposable filters monthly. [...]

Inspectors wroteBased on interview and record review, facility staff failed to notify one resident's (Resident #1's) out of one sampled residents family and physician when a resident leg fell from the wheelchair pedal which resulted in a fracture to the residents leg. The facility census was 26. 1. Review of the facility Change in a Resident's Condition or Status policy, revised May 2017, showed the facility shall promptly notify the residents attending physician and representative of changes in the resident medical/mental condition and/or status. Review showed the nurse will notify the resident's attending physician or physician on call when there is an accident or incident involving the resident. Review showed a significant change of condition is a major decline that will not normally resolve itself without intervention by staff. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to perform hand hygiene as often as necessary, using approved techniques, to prevent cross-contamination. Facility staff failed to ensure hair coverings remained in place during the service of resident meals to prevent the potential for food contamination. Facility staff failed to maintain kitchen equipment and surfaces in a clean sanitary manner to prevent the potential for cross-contamination. Facility staff failed to store food in a manner to prevent contamination and out-dated use. Facility staff failed to ensure the dish washing machine functioned properly before using it to sanitize kitchen wares. The facility census was 30. 1. Review of the policies provided by the facility showed the policies did not contain a hand washing or hair covering policy. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain professional standards of care when they failed to complete a neurological assessment (evaluation completed by staff for early detection of nervous system damage following head trauma), an incident report or post fall 72 hour monitoring for one resident (Resident #1) who had an unwitnessed fall. The facility staff failed to obtain an order to crush medications for two residents (Resident #20 and #21) prior to administering and failed to obtain a supplement order for one resident (Resident #279). The facility census was 30. 1. Review of the facility's Neurological Assessment policy, revised October 2010, showed staff were directed as follows: -Neurological Assessments are indicated following unwitnessed fall; -Perform neurological check with frequency as ordered or per fall protocol. [...]

Inspectors wroteBased on observation, interview and record review facility staff failed to ensure the residents environment remained free of accident hazards when staff failed to lock the treatment cart, treatment room door and the shower room door. The facility census was 30. 1. Review of the facility's Storage of Medications policy, revised April 2007, showed staff were directed as follows: -The nursing staff shall be responsible for maintaining medication storage AND preparation areas in clean, safe, and sanitary manner; -Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. 2. Observation on 11/20/23 at 9:24 A.M., 9:39 A.M., 11:56 A.M., 1:43 P.M. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to store medications in a safe and effective manner for four sampled medication carts. The facility census was 30. 1. Review of the facility's Storage of Medications policy, revised April 2007, showed staff were directed as follows: -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 clean, safe, and sanitary manner; -Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure two residents (Resident #17, and #21) were treated in a dignified and respectful manner. The facility census was 30. 1. Review of the facility's Resident Rights policy, dated September 2022, showed the resident has the right to choose activities, schedules(including sleeping, and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part. Review of the facility's Quality of Life -Dignity policy, revised August 2009, showed: -Residents shall be treated with dignity and respect at all times; -Staff shall speak respectfully to residents at all times; -Staff shall treat cognitively impaired residents with dignity and sensitivity. 2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain personal medical information in a manner to protect seven residents' (Residents #2, #3, #20, #21, #279, #289 and one unidentified resident) privacy. The facility census was 30. 1. The facility's Health Insurance Portability and Accountability Act (HIPPA) policy, dated 2018, showed: -It is the facility's policy to comply with the organizational, policy an procedural, and documentation requirements of HIPPA; -Implement administrative, physical, and technical safeguards that reasonably appropriately protect the confidentiality, integrity, and availability of the electronic protected health information that it creates, receives, maintains, or transmits. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure the arbitration agreement was explained in a form and manner which correctly describes the arbitration process. The census was 30. 1. Review of the facility's policies showed staff did not provide a policy for Arbitration Agreements. Review of the facility's admission Packet showed a one page Arbitration Agreement that did not contain a place to decline arbitration. During an interview on 11/22/23 at 10:40 A.M., the Social Services Director (SSD) said he/she explains the agreement of the arbitration to new residents and their family at admission. The SSD said he/she lets them know if they sign, it avoids court costs and they will use a mediator to resolve the issue, however if you feel it wasn't handled right you can get an attorney. [...]

Inspectors wroteBased on staff interview and record review, facility staff failed to meet professional standards when staff did not document they administered one resident's (Resident #1) Fentanyl patch (a narcotic pain reliever) retrieved from the facility's Emergency Kit to alert staff of the need to remove the patch prior to application of a new one, leaving two patches on at the same time. The facility census was 29. 1. Review of the facility's Administering Medications Policy, dated December 2012, showed the Director of Nursing (DON) will supervise and direct all nursing personnel who administer medication and/or have related functions. Review showed medications shall be administered in a safe and timely manner, and as prescribed. [...]