Stonebrook Health and Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to investigate and report an injury of unknown origin for one of 3 residents (Resident 1) when a family member (FM) reported that she saw a bruise on Resident 1's head. This failure had the potential to put residents at risk of injury without an investigation of the cause, and could possibly compromise Resident 1's safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to post the daily staffing information daily. This failure had the potential to result in nurse staffing misinformation to residents, families, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper drying of cooking/serving equipment, when a large baking pan and three steam table pans were stacked while still wet. This failure had the potential to cause foodborne illness (illness resulting from contaminated food) for 67 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that alternatives were attempted and documented prior to using side rails (devices attached to the side of a bed) for 32 of 68 sampled residents (Residents 1, 4, 6, 12, 16, 17, 18, 25, 26, 31, 32, 33, 43, 48, 50, 51, 56, 59, 70, 82, 83, 84, 86, 87, 88, 89, 93, 94, 95, 96, 100, and 101) reviewed for side rail use.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program to prevent the spread of infections as evidenced by:1. Licensed nurses did not know the process to disinfect a glucometer (blood glucose meter to measure and display the amount of sugar [glucose] in your blood) according to manufacturer's instructions;2. Resident 52's urinary catheter bag (a bag that is attached to a tube that is connected to the bladder) was touching the floor; and3. The Certified Nursing Assistant (CNA) did not perform hand hygiene after removing her gloves and prior handling the new clean bed linens. These failures had the potential to compromise resident's health and safety in the facility.1. During a medication administration observation on 7/28/25 at 11:40 a.m. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to maintain resident's rights to privacy and confidentiality to one of 17 sampled residents (Resident 72) when Resident 72's personal information and care instruction was posted in the room visible to roommates and visitors. This failure had the potential to compromise residents' rights and dignity.

Inspectors wroteBased on interview and record review, the facility failed to document the status of Advance Directive for two of 24 residents (Resident 8 and 44), when no advance directive was located in the electronic records, nor was section D of the POLSTs filled out. This failure had the potential of the facility not following the wishes of the residents in the event of incapacitation and need for life saving treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that resident's enteral feeding (liquid nutrition directly delivered to the stomach using a tube) bottle was properly labeled for one of three sampled residents (Resident 2). This failure had the potential to cause an error during administration of the enteral feeding formula for Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure intravenous (IV) therapy (the administration of parenteral fluids or medications through an IV catheter to treat a condition) was labeled for one of four sampled residents (Resident 31). This deficient practice had the potential to compromise Resident 31's health and well-being.

Inspectors wroteBased on interview, and record review, the facility failed to provide adequate monitoring for three of 17 sampled residents (Resident 72, 52, and 31) when:Resident 72 was not monitored for psychotropic side effects on abnormal involuntary movement based on Medication Regimen Review (MRR); andResident 52 and 31 were not monitored for signs and symptoms of hypo/hyperglycemia (too low/high blood sugar) as indicated in the care plan. These failures had the potential for side effects to go undetected or recognized for timely interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications and biologicals were appropriately stored and labeled during an inspection of randomly selected two of three medication storage when the following were found:1. An injectable medication pen was opened and used with no date.2. Medication that required refrigeration was stored inside the medication cart. These failures had the potential for the administration of expired or deteriorated medications or biologicals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper technique was used for checking the quaternary sanitizer (a group of chemicals used for a variety of purposes including as preservatives, surfactants, antistatic agents, and as active ingredients in disinfectants and sanitizers), when a kitchen staff member did not follow the instructions on the container for the test strips that were used. This failure had the potential of the strength of the sanitizer not being appropriate to kill any microbes, thus spreading food borne pathogens and illness to the facility occupants, which there were 67 of 68 residents who ate food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food preferences were honored for one of 17 sampled residents (Resident 90). This failure resulted in Resident 90 receiving food items she disliked.

Inspectors wroteBased on interview and record review, the facility failed to offer pneumococcal vaccines (vaccines that help prevent serious infections caused by pneumonia, a lung infection) as required for two of five sampled residents (Residents 36 and 72). This failure had the potential to place residents at risk for preventable disease.

Inspectors wroteBased on interview and record review, the facility failed to complete and submit an investigation summary regarding an alleged abuse incident that occurred between two of three sampled residents (Residents 1 and 2). This failure had the potential to compromise the facility's ability to determine the circumstances surrounding the incident and could have compromised the residents' safety.

Inspectors wroteBased on interview, record review, and document review, the facility failed to complete and transmit discharge Minimum Data Set (MDS) assessments for 2 (Resident #38 and Resident #51) of 2 sampled residents reviewed for resident assessment.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) had a physician's order to go out on pass (to leave the premises). This failure had the potential to compromise the resident's safey. Also for Resident 1, the facility failed to ensure a written summary of the baseline care plan (plan that includes the minimum information necessary to properly care for the resident upon admission) was given to the responsible party (RP, person designated to make decisions on behalf of the resident). This failure had the potential to compromise the resident's right to be informed of and participate in the plan of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services in accordance with professional standards of practice when: 1. For Resident 201, the daily weight and the fluid restriction orders were not followed; 2. For Resident 204 the PICC line external catheter length was not measured during each dressing change and flushes were not performed; 3. For Resident 217, dressing changes and flushes were not performed for the PICC line; 4. For Resident 2, physician order for left arm sling use was not followed; 5. For Resident 249, the PICC line external catheter was not measured upon admission and during dressing change; 6. For Resident 46, the left hemi arm tray use was not followed. 7. For Residents 5, 13 and 149, the nurses did not check the residents' heart rate (HR) prior to the medication administration 8. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic drugs (medications that are capable of affecting the mind, emotions, and behavior) for three of 15 sampled residents (Residents 8 and 12) when: There was no accurate behavior monitoring, monthly behavior summary, and GDR (gradual dose reduction) for Residents 8 and 12's Remeron (antidepressant) use. There was no psychotic and hypnotic assessment completed when Resident 12 had significant change of condition. These failures resulted in the unnecessary drugs use for these residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications and biologicals were stored, labeled and disposed appropriately when inspections of two of three medication carts found: 1. Medication Cart #1 a. Multiple opened insulin pens and insulin multidose vial not dated. b. Multiple controlled medications (those with high potential for abuse or addiction) of discharged or transferred residents and discontinued medications were kept at the locked compartment containing controlled medications were identified. c. Multiple liquid medications of either discharged /transferred residents were not dated and stored in the medication cart. d. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored and prepared under sanitary conditions when: 1. There were black patches on the wall behind the refrigerator, 2. Plastic containers in the storage shelf were still wet, 3. The red bucket (sanitizer bucket) and green bucket (soapy water or clean rinse water) were on top of the food preparation area, 4. There was a cup of coffee next to the coffee machine, without a lid on, and a purse on top of the food preparation table, next to the food spices. These failures had the potential to cause food contamination and illness to 58 residents who received their food from the kitchen.

Inspectors wrote2. During an observation and interview on 8/2/21, at 10:04 a.m., in Resident 18's room resident was awake and alert, and sitting in bed. The surveyor observed a bottle of Refresh Tears eye drops (used as a lubricant for dry eyes) on top of the resident's bedside drawer. The surveyor observed the resident applying solution on both eyes. The resident stated she used it for her dry eyes. A review of Resident 18's clinical record indicated no physician's order or care plan in place to self-administer her own medications. During an interview with registered nurse L (RN L) on 8/2/21, at 2:25 p.m., surveyor informed RN L about the Refresh Tears Eye Drops at Resident 18's bedside. RN L stated that she already removed the eye drops and that there was no physician's order for it. She said family left it at bedside. [...]

Inspectors wroteBased on interview and record review, the facility failed to make appropriate referral for Level II preadmission screening and resident review (PASRR, a comprehensive evaluation conducted by a state-designated authority that determines whether an individual has a mental disorder (MD), intellectual disability (ID), or a related condition as defined above, determines the appropriate setting for the individual, and recommends what, if any, specialized services and/or rehabilitative services the individual needs), for one of 15 sampled residents (Resident 4). This failure may lead to denying specialized services and rehabilitation services available for Resident 4 and may limit her capacity to reach their highest mental, physical, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the care plan (provides direction on the type of nursing care the individual may need) to monitor intake and output (I &O) for one of 15 sampled residents (Resident 44) who had a jejunotomy tube (JT, a soft, plastic tube placed through the skin of the abdomen into the midsection of the small intestine used for administration of food and medications). This failure had the potential to result in the inability to identify the resident's hydration status/needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision and implement interventions to prevent falls for one of 12 sampled residents (Resident 4). The minimum data set (MDS, an assessment tool) did not accurately code the fall incident that resulted in an injury that required hospital transfer for evaluation and treatment. This failure could have resulted in a fall with possible injury without the surveyor's intervention by calling staff's immediate attention to the situation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction) when: 1. Discontinued controlled medications for multiple discharged residents were not removed timely from one of two medication carts (Med Cart #1) to prevent medication errors and potential for loss and misuse; and 2. The random controlled medication use audit for one resident (Resident 208) did not reconcile. The medication signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) was not consistent with the amount taken and administered to Resident 208. This failure had the potential for misuse or diversion of controlled medications.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the pharmacy consultant's identified and reported drug irregularities to the attending physician and the facility's medical director and director of nursing, for 2 of 15 sampled residents (Residents 8 and 12). This failure could result in the continued use of unnecessary psychotropic medications for the two residents. A review of Resident 8's physician order dated 2/26/21 indicated Remeron 7.5 milligram (mg, unit of measurement) one tablet by mouth at bedtime for depression as manifested by poor appetite. Her monthly Psychotropic Summary and monitoring of the number behavior episodes were not done. A review of Resident 12's physician's order dated 7/27/2020 indicated Remeron 15 mg. one tablet by mouth at bedtime for depression manifested by poor appetite. [...]

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 6.67% when two medication errors occurred out of 30 opportunities during medication administration for two out of ten residents (Residents 5 and 149). The deficient practice resulted in medications not given in accordance with the prescriber's orders and/or manufacturer's specifications, which may result in residents not receiving the full therapeutic effect of the medications and could potentially compromise the residents' medical health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the dietary aide (DA) knew how to check the dishwasher's temperature. This failure had the potential to affect 58 residents who received meals in the facility. A kitchen observation and interview were conducted with the dietary aide (DA), on 8/4/21, at 12:10 p.m., with the registered dietitian (RD) and the assistance of the cook to interpret. The DA, assigned in the dishwashing station, did not know how to check the temperature of the dishwasher. RD said the dishwasher was acquired in June, 2021. During an interview and record review with the RD on 8/5/21 at 3:30 p.m., RD said the DA has various kitchen duties, but mostly assigned to work in the dishwasher. [...]

Inspectors wroteBased on interview and record review, the skilled nursing facility did not coordinate hospice care for two of two sampled residents (Residents 26 and 150). Facility staff did not have a schedule for hospice nursing visits (RN, registered nurse and CNA, certified nursing assistant) and documented communication/coordination with hospice services. These failures resulted in the potential for lack of continuity of care for Residents 12 and 26 who were receiving hospice services at the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to follow infection control measures when staff did not properly handle dirty linens and when the oxygen concentrator's filters were not changed for Residents 22 and 2. This failure had the potential to spread infection to self and others.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a functional and safe environment for 2 out of the 26 sampled residents (Residents 43 and 46) related to bedside tables with rough edges, peeled paint on wall, and a broken phone line. These failures had the potential to affect the safety and well-being of the residents in the facility.