Stonebridge Villa Marie

Inspectors wroteBased on observation, interview, and record review, facility staff failed to remove and discard discontinued medication and improperly labeled medication from two of two medication carts and one of two medication rooms. The facility census was 62.1. Review of the facility's policy titled Labeling of Medication Containers, revised 04/07, showed medications shall contain the expiration date when applicable. Review of the facility's policy titled Storage of Medications, revised 04/07, showed the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals, all such drugs shall be destroyed. Review of the facility's policy titled Discarding and Destroying Medications, revised 10/16, showed medications will be disposed of in accordance with federal, state, and local regulations.2. Observation on 03/12/26 at 9:46 A.M., showed the rehabilitation medication cart contained: [...]

Inspectors wroteBased on observation, interview, and record review, 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) to prevent or minimize exposure to hazards) for four residents (Resident #1, #5, #20, and #28) of 17 sampled residents. The facility census was 62.1. Review of the facility policy titled Enhanced Barrier Precautions, dated 04/04/24, showed it is the policy of this facility to implement EBP for the prevention of transmission of multidrug-resistant organisms (MDRO). [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to develop a comprehensive care plan to reflect the care needs of two residents (Resident #1 and #28) out of 17 sampled residents. The facility census was 62. 1. Review of the facility's policy titled Care Plans, Comprehensive Person Centered, revised 10/17, showed: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -The Interdisciplinary Team (IDT), in conjunction with the resident and his/her representative develops and implements a comprehensive, person-centered care plan for each resident; -Assessments of residents are ongoing, and care plans are revised as information about the residents and the resident's condition change; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to update care plans to address the care needs of four residents (Residents #6, #7, #20, and #43) out of 17 sampled residents. The facility census was 62.1. Review of the facility policy titled Care Plans, Comprehensive Person-Centered, dated March 2017, showed a comprehensive, person-centered care plan will describe services that would otherwise be provided but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; and will aid in preventing or reducing decline in the resident's functional status and/or functional levels. Assessments of residents are ongoing, and care plans are revised as information about the residents and the resident's condition change. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to document falls and neurological assessment for one resident (Resident #1) of two sampled residents. The facility census was 62.1. Review of the facility's policy titled Falls, revised 04/22 showed staff will evaluate and document falls that occur including an observation of the event identifying them as witnessed or unwitnessed. The nurse will assess and report the resident's neurological status; Review of the facility's policy titled Neurological Assessment, revised 10/2010, showed a neurological assessment is to be completed upon physician's order, after an unwitnessed fall, after a fall with suspected head injury, and when indicated by resident condition. Perform neurological checks with frequency as ordered per fall protocol. If the resident refused the procedure document the refusal. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to obtain orders for a Bilevel Positive Airway Pressure (BiPAP) (a noninvasive ventilator) for one resident (Resident #2) of one sampled. The facility census was 62.1. Review of the facility's policy titled Oxygen Safety, revised 01/18, showed staff, residents and families will be educated on oxygen safety precautions in accordance with their roles and responsibility. Review of the facility's policy titled BiPAP Support, revised 03/25, showed only a qualified and properly trained staff member should administer oxygen through a BiPAP mask. Review the physician's order to determine the oxygen concentration and flow, and the Positive End Expiratory Pressure (PEEP) pressure for the machine. 2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to obtain physician's orders for the use of side rails for two residents (Resident #2 and #23) of three sampled residents. The facility census was 62. 1. Review of the facility's policy titled Proper Use of Side Rails, revised 09/22, showed the facility will obtain a physician's order for the use of the specific side rails and medical diagnosis, condition, symptoms, or functional reason for the use of side rails. 2. Review of Resident #2's Significant Change Minimum Data Set (MDS), dated [DATE], showed staff assessed the resident as cognitively intact. Review of the resident's care plan, revised 02/21/26, showed staff documented a physician's order will be current for side rails to be used. Review of the resident's Physician Order Sheet (POS), dated 03/10/26, did not contain orders for side rail use. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to post the required telephone number to the Department of Health and Senior Services (DHSS) hotline (to report allegations of abuse and neglect), or a list of names, addresses, and phone numbers of the State Survey Agency (SA) in an accessible location for residents and visitors to view in the memory care unit. The census was 62.1. Review of the facility's policy titled, Facility Postings, undated, showed facility staff will post the required postings in an area accessible to all staff and residents. Facility postings should include a list of names, addresses (mailing and email), and a telephone number of all pertinent state agencies including the SA. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to change gloves and wash/sanitize hands during perineal care for two residents (Resident #1, and #2) of two sampled residents, and failed to properly dispose of contaminated linens from one resident's (Resident #3's) room. Facility staff failed to implement the enhanced barrier precautions (EBP) (an infection control intervention) policy when they did not properly alert staff of residents who required EBP and place appropriate personal protective equipment (PPE) in proximity for one resident (Resident #1) of one sampled resident that required EBP during perineal care and wound care. The facility census was 68. 1. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to review and revise the plan of care with changes in the resident's needs for three residents (Resident #4, #5, and #6) out of three sampled residents. The facility census was 68.1. Review of the facility's Comprehensive Care Planning policy, dated 02/25, showed staff are directed as followed:-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 [NAME] and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality; [...]

Inspectors wroteBased on record review and interview, facility staff failed to thoroughly investigate an allegation of sexual assault for one resident (Resident #1) out of one sampled resident. The facility census was 69. 1. Review of the facility's policy titled, Abuse, Neglect, and Exploitation Program Responsibilities, dated September 2022, showed staff are directed as follows: -abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology; -The Abuse Coordinator in the facility is the Administrator, or facility appointed designee when the Administrator is absent. -Report allegations or suspected abuse, neglect, or exploitation immediately to the Administrator, Law Enforcement, and State Survey and Certification Agency through established procedures. --For investigation of alleged abuse, neglect and exploitation: [...]

Inspectors wroteBased on record review and interview, facility staff failed to contact local law enforcement, and failed to report to the Department of Health and Senior Services (DHSS) within the two-hour required timeframe for one resident (Resident #1) out of one sampled resident with an allegation of sexual abuse. The facility's census was 69. 1. Review of the facility's policy titled, Abuse, Neglect, and Exploitation Program Responsibilities, dated September 2022, showed staff are directed as follows: -Abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology; [...]

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 66. 1. Review of the facility's Food Services Manager policy, dated December 2008, showed the daily functions of the Food Services Department are under the supervision of a qualified Food Services Manager. The Food Services Manager is a qualified supervisor licensed by this state and is knowledgeable and trained in food procurement storage, handling, preparation, and delivery. Review of the dietary manager's (DM) personnel records showed a hire date for the DM position listed as 07/28/24. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to serve food in accordance with the nutritionally calculated menus to all residents. The facility census was 66. 1. Review of the facility's Menus policy, dated October 2008, showed the policy directed that menus shall meet the nutritional needs of the residents, be prepared in advance and be followed. 2. Review of the facility menus, dated 08/08/24 (Week 2, Day 12), showed the menus directed staff to provide the residents on regular and dental/mechanical soft diet with a two inch by three inch cream cheese brownie at the lunch meal. Observation on 08/08/24 at 12:16 P.M., showed dietary staff with the noon meal,did not prepare or serve the cream cheese brownies as directed by the menus to residents who received regular and dental/mechanical soft diets. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to store food in a manner to prevent potential contamination and outdated use. Facility staff failed to thaw frozen foods in a manner to prevent the growth of food-borne pathogens and cross-contamination with ready-to-eat food items. Facility staff failed to allow sanitized dishes to air dry before being stacked in storage to prevent the growth of food-borne pathogens. Facility staff failed cover kitchen waste containers when not in actual use to deter the attraction of pests and rodents. Facility staff failed to perform hand hygiene as often as necessary, using approved techniques, to prevent cross-contamination. These failures have the potential to affect all residents. The facility census was 66. 1. Review of the facility's Food Receiving and Storage policy, dated July 2014, showed: [...]

Inspectors wroteBased on interview and record review, facility staff failed to designate one or more individuals with specialized training in Infection Prevention and Control (IPC) as the Infection Preventionist (IP) for the facility's infection prevention and control program. The facility census was 66. 1. Review of the facility's policies showed staff did not provide a policy in regard to the qualifications of the Infection Preventionist. 2. During an interview on 08/08/24 at 12:22 P.M., Licensed Practical Nurse (LPN)/Assistant Director of Nursing (ADON) said he/she enrolled in the required IP training Monday night or Tuesday morning after the DON put his/her notice in. The LPN/ADON said he/she is not a trained IP. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure Level I Pre-admission Screening (used to evaluate for the presence of psychiatric conditions to determine if a Pre-admission Screening and Resident Review (PASARR) level II screen is required) were completed for three (Resident #25, #48 and #59) of seven sampled residents. The facility census was 66. 1. Review of the facility's PASARR Procedure policy, undated, showed staff are instructed as follows: -Regardless of source of payment and on the day of acceptance of the referral the Clinical Liaison will request a completed DA-124 A/B (form for the PASARR), a federally mandated screening process for individual with serious mental illness and/or mentally regarded/developmental disability related diagnosis who apply or reside in Medicaid Certified beds in a nursing facility; [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to ensure prepared food items were served at a safe and appetizing temperature when the facility staff failed to maintain the internal temperatures of hot food items placed in hot holding at 140º F or higher. Facility staff also failed to reheat pureed food items to an internal temperature of 165 degrees Fahrenheit (º F) before service to prevent the growth of food-borne pathogens and potential for food-borne illness. These failures have the potential to affect all residents who dined in one of two dining rooms. The facility census was 66. 1. Review of the facility's Food Preparation and Service policy, dated July 2014, showed: -Food service employees shall prepared and serve food in a manner that complies with safe food handling practices; -The danger zone for food temperatures is between 41º F and 135º F . [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to prepare and serve food items at an appropriate texture for 10 of 10 residents (Residents #9, #20, #24, #25, #29, #32, #47, #48, #51 and #58) who received dental/mechanical soft diets. The facility census was 52. 1. Review of the facility's Menus policy, dated October 2008, showed the policy directed menus shall meet the nutritional needs of the residents, be prepared in advance and be followed. Review of the facility's Standardized Recipes policy, dated April 2007, showed the policy directed standardized recipes shall be developed and used in the preparation of foods and only tested, standardized recipes will be used to prepare foods. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Director of Nurses (DON) did not work as a charge nurse when the facility had an average daily occupancy of 60 or more residents. This had the potential to affect all residents at the facility. The census was 68. 1. Review of the facility's Sufficient Nursing Staff policy, dated October 2022, showed The DON may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. Review of the Facility Assessment, dated 11/1/22, showed the following: -The fluctuations in census and acuity may impact staffing needs; -One DON Registered Nurse (RN) full time; -One RN on the dayshift. -Two licensed practical nurse (LPN) for each shift. -Two nursing staff with Administrative duties on the dayshift; -Dayshift is identified as 7:00 A.M. to 7:00 P.M. and Nightshift is identified as 7:00 P.M. [...]

Inspectors wroteBased on observation, interviews, and record reviews, facility staff failed to prepare food according to recipes and to ensure residents with pureed diets received all items on the menu. This failure had the potential to affect all facility residents. The census was 68. 1. Review of the facility's Meatloaf recipe, undated, showed staff were directed to use 16 ¾ pound (lb) of ground beef for 67 three-ounce servings. Observation on 5/17/23 at 9:44 A.M., showed [NAME] M prepared meatloaf for the residents' lunch meal. Further observation showed [NAME] M added 15 lb of ground beef to the meatloaf mixture. Staff served the meatloaf to the resident's for lunch. During an interview on 5/17/23 at 9:48 A.M., [NAME] M said the recipe called for 17 ½ lb of ground beef, but he/she thought it was too much. The cook said 15 lb would be enough ground beef. 2. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility staff failed to ensure the ice machine drained through an air gap, to properly store open food to prevent cross contamination and outdated usage, and to maintain the kitchen in a clean and sanitary manner. The facility staff also failed to perform hand hygiene as often as necessary. The census was 68. 1. Review of the facility's policies and procedures showed the facility did not have a policy on the inspection and maintenance of the ice machine. Observation on 5/16/23 at 2:00 P.M., showed the ice machine, located in the kitchen, did not drain through an air gap. Further observation showed staff served the ice to residents throughout the day. During an interview on 5/16/23 at 2:03 P.M., the maintenance director said he was not aware the ice machine should drain through an air gap. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to meet professional standards of care when staff failed to obtain and document weights for four residents (#12, #20, #30, and #67). The facility census was 68. 1. Review of the facility's Weight and Measuring the Resident policy, dated March 2011, showed: -The purpose is to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident; -Weight is usually measured upon admission and monthly during the resident's stay; -The weight should be documented in the medical record; -If the resident refused the weight, it should be documented in the medical record; -Report significant weight loss/gain to the nurse supervisor. 2. [...]

Inspectors wroteBased on observation, interview, and record review facility staff failed to assist five out of 17 sampled dependent residents (Resident #8, #25, #29, #41, and #56) with grooming and bathing, and failed to assist three dependent residents (Resident #18, #35, and #62) during meals. The facility census was 68. 1. Review of the facility's policy Activities of Daily Living (ADLs), Supporting, dated March 2018, showed staff were directed as follows: -Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living; -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 ensure the resident's environment remained free of accident hazards when they failed to properly propel four residents (Resident #13, #18, #68 and one unknown resident) in wheelchairs in a manner to prevent accidents, failed to ensure hazardous chemicals were stored in a safe manner, and failed to provide safe mechanical lift transfers for one resident (Resident #8). The facility census was 68. 1. Review of the facility policies showed the facility did not provide a policy for wheelchair safety. 2. Review of Resident #13's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 5/6/23, showed staff assessed the resident as: -Cognitively impaired; -Used a wheelchair. [...]

Inspectors wroteBased on observation, interview, and record review facility staff failed to store and label medication in a safe and effective manner for two sampled medication carts and one medication storage room. The facility census was 68. 1. Review of the facility's Storage of Medications policy, dated April 2017, showed staff are directed as follows: - Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received; - Drug containers that have missing, incomplete, improper, or incorrect labels hall be returned to the pharmacy for proper labeling before storing; - Medications requiring refrigeration must be store in a refrigerator located in the drug room at the nurses; station or other secured location under proper temperature controls. - The facility shall not used discontinued, outdated, or deteriorated drugs or biologicals. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to use appropriate hand hygiene during incontinence care for one resident (Resident #9) and failed to use appropriate hand hygiene before and after medication administration for 10 residents (Resident #6, #7, #8, #15, #16, #31, #33, #44, #45, and #48). The facility census was 68. 1. Review of the facility's Hand Hygiene policy, dated 2017, showed: -appropriate hand hygiene is essential in preventing transmission of infectious agents; -hand hygiene continues to be the primary means of preventing the transmission of infection; -Hand hygiene (e.g., handwashing and/or Alcohol Based Hand Rub (ABHR): [...]

Inspectors wroteBased on interview and record review, facility staff failed to maintain and follow current guidance and procedures for immunizations of residents against pneumococcal pneumonia (infection caused by bacteria) in accordance with national standards of practice for four (Residents #9, #41, #42 and #55) of six sampled residents. The facility census was 68. 1. Review of the facility's Resident Immunization and Vaccinations policy, revised 12/01/22, showed: -The pneumococcal vaccine program as recommended by the Center for Disease Control and Prevention (CDC) varies for patients by age group. The recommendations, updated in 2022, are as follows: -Follow current CDC recommendations for vaccination schedules and dose; -Nursing Procedure: --Upon admission, follow CDC guidelines to assess immunization eligibility requirements; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to plan interventions and update the care plan; failed to complete a Braden scale assessment (tool to assess risk for developing pressure injury) for three weeks after admission; failed to document a weekly skin assessment on 5/5/23; failed to document measurements, appearance, odor, pain, or presence of drainage of the wound; and failed to consult with the dietician regarding the presence of a new unstageable pressure injury (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar (dead tissue) wound for one resident (Resident #9). The facility census was 68. 1. Review of the facility's Pressure Injury Prevention and Management Policy, dated October 2018, showed: [...]