Stonebridge Owensville

Inspectors wroteBased on interview and record review, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. This failure has the potential to affect all residents. The facility census was 72.1. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to ensure the mechanical dishwasher operated according to manufacturer's instructions in a manner adequate to prevent cross-contamination of kitchen wares. This failure has the potential to affect all residents. The facility census was 72.1. Review of the facility's policy titled Dishwashing Machine Use, revised March 2010, showed: -The operator will check temperatures using the machine gauge with each dishwashing machine cycle, and will record the results in facility approved log;-The operator will monitor the gauge frequently during the dishwashing machine cycle. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to properly clean and maintain wheelchairs for three residents (Resident #41, #45 and #37) of a sampled of 20 residents. The facility census was 72. 1. Review of the Facility's policy titled, Wheelchair Cleaning Procedure, undated, showed staff are to make sure no visible dirt, foot, etc. on any part of the wheelchair. Provides wheelchair cleaning schedule to cover all wheelchairs in the facility to be cleaned once a week. 2. Review of the Facility's policy titled, Creating a New Work Order in Technology Efficiency Life Safety and Services (TELS), undated, showed staff are directed how to place a work order for maintenance, when staff observe items needing to be repaired. 3. [...]

Inspectors wroteBased on interview and record review, facility staff failed to screen eight employees (Registered Nurse (RN) AA, Laundry Aide Z, Laundry Aide X, Dietary Aide Y, Certified Nurse Aide (CNA) S, [NAME] V, Nurse Aide (NA) T and Licensed Practical Nurse (LPN) U) out of ten new employees prior to employment to determine if the employees had indicators on the CNA Registry, Family Care Safety Registry (FCSR), Criminal Background Check (CBC) and/or Employee Disqualification List (EDL). The facility census was 72. 1. Review of the Facility's policy titled, Background Screening Investigations, dated March of 2019, showed the facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on all applicants. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to use proper hand hygiene and provide perineal care in a manner to reduce the risk of infection for one resident (Resident #32) out of three sampled residents, facility staff failed to use Enhanced Barrier Precautions (EBP) (an infection control practice that requires staff to wear personal protective equipment (PPE) (protective equipment such as gowns, gloves, goggles, and masks used to prevent or minimize exposure to hazards) for one resident (Resident #66) out of three sampled residents; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to document a complete and accurate Minimum Data Set (MDS) assessment (a federally mandated assessment tool), when they did not accurately code anticoagulant use for two residents (Resident #5 and #6), oxygen and/or Continuous Positive Airway Pressure (CPAP - Machine that keeps the airways open during sleep for persons with sleep apnea) use for two residents (Resident #1 and #4), falls with injury for one resident (Resident #3), and a psychiatric diagnosis for one resident (Resident #41) out of 20 sampled residents. The facility census was 72. 1. Review of the facility policy titled, MDS Completion and Submission Timeframes, dated July 2017, showed the facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to develop measurable goals and interventions for comprehensive care plans and update existing care plans to reflect care needs for four residents (Residents #4, #11, #23, and #41) out of 20 sampled residents. The facility census was 72.1. Review of the facility's policy titled Comprehensive Care Plans, dated 09/22, showed 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; -The Comprehensive care plan will describe at a minimum, the following: -The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; -The residents' goals for admission, desired outcomes, and preferences for future discharge; [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide an ongoing activity program designed to meet the residents' interest, mental, and psychosocial well-being on the weekends for three residents (Resident #4, #23, and #28) out of 20 sampled residents. The facility census was 72.1. Review of the facility's policy titled, Life Enrichment Program, dated 10/2017, showed facility-sponsored group and individual activities and independent activities will be designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, as well as encourage both independence and interaction within the community. 2. Review of the facility's Activity Calendar, dated February 2026, showed: -Saturdays, 02/07, 02/14, 02/21, 02/28 Games/Puzzles;-Sundays, 02/01, 02/15 Games/Puzzles;-Sunday, 02/08 Superbowl Sunday 5 P.M. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide care and services to meet professional standards in regard to the use of a Continuous Positive Airway Pressure (CPAP) device, the standard treatment for obstructive sleep apnea using a mask and gentle air pressure to keep airways open during sleep, when facility staff failed to obtain an order for the use of the CPAP, and include the use of CPAP on the resident's care plan, for one resident (Resident #1) of two sampled residents. The facility census was 72. 1. Review of the facility policy titled CPAP/Bi-level positive airway pressure (BiPAP) Support, dated March 2025, showed the following: -Review the physician's order to determine the oxygen concentration and flow, and the Positive End-Expiratory Pressure (PEEP) pressure for the machine; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to complete entrapment assessments for five residents (Resident #11, #32, #63, #66, and #70) who used bed rails out of 20 sampled residents. The facility census was 72. 1. Review of the facility's policy titled Proper Use of Side Rails, dated 09/2022, showed:-The resident assessment should assess the resident's risk of entrapment between the mattress and bed rail or in the bed rail itself;-Inspecting and regularly checking the mattress and bed rails for areas of possible entrapment;-Ensuring the bed frame, bed rail, and mattress do not leave a gap wide enough to entrap a resident's head of body, regardless of mattress width, length, and/or depth;-The maintenance director, or designee, is responsible for adhering to a routine maintenance and inspection schedule of all bed frames, mattresses, and bed rails.2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to safely transfer one resident (Resident #1) out of two sampled residents in a manner to prevent accidents when staff failed to use a gait belt during a transfer which resulted in a fracture. The facility's census was 73. The administrator was notified on 11/26/25 of past Non-Compliance which occurred on 11/16/25 when the administrator implemented new policies and procedures to ensure the nursing staff safely transferred residents. Staff were in-serviced on 11/16/25 regarding how to safely transfer a resident.1. Review of the facility's Safe Lifting and Movement of Residents policy, dated 07/2017, showed to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate decisions regarding the safe lifting and moving of residents. [...]

Inspectors wroteBased on interview and record review, facility staff failed to administer medications as ordered by the physician when Licensed Practical Nurse (LPN) D prepared insulin for Resident #2, and the Assistant Director of Nursing (ADON) administered the insulin to Resident #1 and facility staff failed to document a medication error in the resident's medical record. The facility census was 78. 1. Review of the facility's medication administration policy, dated December 2024, showed the individual administering the medication must check the label to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document appropriately in the clinical chart. 2. [...]

Inspectors wroteBased on interview and record review facility staff failed to ensure one resident (Resident #1) remained free from accidents when staff failed to prevent Resident #1 from ingesting Resident #2's medications. The facility census was 83. The administrator was notified on 04/08/25 of past Non-Compliance which occurred on 03/29/25. when Resident #1 ingested Resident #2's medications. Staff assessed the resident, and notified the required parties and agencies. The administrator immediately in-serviced all nursing staff in-serviced nursing staff on medication administration. Staff corrected the deficient practice on 4/02/25. 1. Review of the facility's Administering Medications Policy, updated 12/2012, showed staff are to verify the resident's identity three times before administering the medication. [...]

Inspectors wroteBased on interview and record review, facility staff failed to prevent misappropriation of one residents (Resident #1's) out of four sampled residents when Licensed Practical Nurse (LPN) A misappropriated the resident's Oxycodone (an Opioid analgesic) and Lorazepam (an antianxiety medication). The facility census was 83. The administrator was notified on 04/08/25 of past Non-Compliance which occurred on 03/07/25. Staff immediately suspended LPN A, conducted an investigation, and notified the required parties and agencies. The administrator immediately in-serviced all staff on facility's policy regarding counting narcotics and accounting for medications upon a resident's discharge, and abuse, neglect and misappropriation. The deficiency was corrected on 03/11/25. 1. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide a clean barrier for wound supplies during wound care for two residents (Resident #2 and #3) and failed to perform approved hand hygiene during incontinence care for two residents (Resident #3 and #64) out of 25 sampled residents. Facility staff failed to ensure dietary staff performed hand hygiene as often as necessary using approved techniques to prevent cross-contamination during food preparation and service. The facility census was 71. 1. Review of the facility's policy titled, Dressings, Dry/Clean, dated September 2013, showed staff are directed to do: -Clean bedside stand; -Establish a clean field; -Place clean equipment on the clean field. 2. [...]

Inspectors wroteBased on record review and interview, facility staff failed to complete a baseline care plan within 48 hours of admission for five residents (Resident #1, #2, #6, #28, and #65) out of a sample of 25 residents. The facility census was 71. 1. Review of the facility's policy titled Care plans - Baseline, dated December 2016, showed staff were directed: -A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission; -The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan; -The resident and their representative will be provided a summary of the baseline care plan. 2. Review of Resident #1's medical record showed staff documented the resident admitted to the facility on [DATE]. The record did not contain a baseline care plan. 3. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop and implement a comprehensive person-centered care plan addressing oxygen use for one resident (Resident #14), limited range of motion for one resident (Resident #64), Post Traumatic Stress Disorder (PTSD), a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event, for four residents (Resident #66, #71, #1, and #17), urinary catheter (tube placed directly in the bladder) care for one resident (Resident #2), and Activities of Daily Living (ADL)/transfer needs for one resident (Resident #65) out of 25 sampled residents. The facility census was 71. 1. Review of the facility's policy titled, Comprehensive Care Plans, dated October 2022, showed staff were directed to do the following: [...]

Inspectors wroteBased on interview and record review, facility staff failed to document the administration of medications for five residents (Residents #2, #12, #23, #64 and #65) of 25 sampled residents, on the residents Medication Administration Record (MAR). The facility census was 71. 1. Review of the facility's Documentation of Medication Administration policy, dated April 2007, showed the facility shall maintain a medication administration record to document all medications administered. A Nurse or Medication Medication Aide shall document all medications administered to each resident on the resident's MAR. Administration of medication must be documented immediately after it is given. The documentation must include signature and title of the person administering the medication. 2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to remove and destroy expired medications and biologicals in two of four sampled medication carts, and one of two medication rooms. The facility census was 71. 1. Review of the facility's policy titled Storage of Medications, dated April 2007, showed the facility staff shall store all drugs and biologicals in a safe, secure, and orderly manner. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 2. Observation on 08/27/24 at 8:45 A.M., showed the charge nurse's medication cart contained liquid pain relief acetaminophen 160 milligrams (mg)/5 milliliters (ml), 16 fluid (fl) ounces (oz), 473 (ml), expired 04/24. 3. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide appropriate treatment and services to prevent further decrease in range of motion (ROM), movement of a joint, for one resident (Resident #64), with a contracture (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) to the left hand out of 25 sampled residents. The facility census was 71. 1. Review of the facility's Resident Mobility and ROM policy, dated July 2017, showed residents with limited ROM will receive treatment and services to increase and/or prevent further decrease in ROM. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were in reach for three residents (Resident #42, #64 and #72). The facility census was 74. 1. Review of the facility's policy titled, Call Light Accessibility and Response, dated September 2022, showed staff were directed to do the following: -The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will be directly relayed to a staff member or centralized location to ensure appropriate response; -Staff will ensure the call light is within reach of resident and secured, as needed; -The call system will be accessible to resident while in their bed or other sleeping accommodations within the resident's room. 2. [...]

Inspectors wroteBased on observation and interview, facility staff failed to provide a comfortable and homelike environment by, failing to appropriately clean and maintain walls, handrails, tile floors and furniture in resident living areas. Additionally staff failed to appropriately clean a fall mat and wheelchair for one resident (Resident #50). The facility census was 74. 1. Review of the facility's policy, titled Resident Environmental Quality, dated 2016, showed all facility personnel are responsible for reporting broken, defective or malfunctioning equipment or furnishings immediately upon identification of the issue. 2. Observation on 10/02/23 at 11:57 A.M., showed room [ROOM NUMBER] had missing paint and a hole in the bathroom door. 3. Observation on 10/02/23 at 11:20 A.M., showed room [ROOM NUMBER] walls had nail holes and black marks and the flooring tiles had brown and black marks. [...]

Inspectors wroteBased on interview and record review, facility staff failed to check the Employee Disqualification List (EDL) (a list of individuals who have been determined to have abused or neglected a resident or misappropriated funds or property belonging to a resident) in accordance with their facility policy for three out of nine sampled staff (Certified Nurse Aide (CNA) O, the Business Office Manager (BOM), and Food Service Aide (FSA) P. Additionally, staff failed to check the Family Care Safety Registry (FCSR) or complete a complete Criminal Background Check (CBC) for three out of nine sampled staff (CNA O, the BOM, and FSA P). The facility census was 74. 1. Review of the facility's policy titled, Background Screening Investigation, dated March 2019, showed staff were directed to do the following: [...]

Inspectors wroteBased on observation, interview and record review facility staff failed to ensure a comprehensive care plan was developed and implemented for eleven residents (Resident #16, #24, #27, #34, #36, #42, #45, #52, #64, #74, and #78). The facility census was 74. 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; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to revise care plans for seven residents (Resident #5, #24, #25, #45, #64, #66 and #74). The facility census was 74. 1. Review of the facility's policy titled, Comprehensive Care Plans, dated September 2022, showed: -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 comprehensive care plan will describe, at a minimum, the following: -The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure three residents (Residents #24, #42 and #45), 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 74. 1. Review of the facility's policy titled, Activities of Daily Living (ADLs), Supporting, dated 2001, 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 activities of daily living (ADLs); -Residents who are unable to carry out activities of daily living 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 post the telephone number for the Department of Health and Senior Services (DHSS) Adult Abuse and Neglect Hotline (used to report allegations of abuse and neglect), the name address and phone number for the Long-Term Care Ombudsman, and resident rights in a form and manner accessible to residents and visitors on the secured memory care unit. The facility census was 74. 1. Review of the facility's policy titled, Facility Postings, undated, showed staff were directed to do the following: -The facility will post required postings in an area that is accessible to all staff and residents; -Facility postings include: [...]