Stonebrook Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety when:The dishwashing machine failed to reach the required sanitization temperature. Two dietary staff did not wear required beard restraints while in food preparation areas. This failure had the potential to result in food contamination and foodborne illnesses for a medically vulnerable population with a census of 114 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure infection prevention and control practices was consistently implemented for three (Resident 88, 72 and 38) of 23 sampled residents when: Airborne Precautions (infection control measures used to prevent the spread of illnesses transmitted by tiny pathogens suspended in the air) for Resident 88 was not followed when the door to resident's room was open. Registered Nurse (RN) 1 did not wear a gown to administer antibiotics intravenously (IV, route directly into the bloodstream) to Resident 72 on Enhanced Barrier Precautions (EBP, infection control intervention used to reduce the transmission of multi-drug-resistant organisms (MDROs) by wearing gown and gloves during high contact resident care activities). [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the rights of one of 23 sampled residents (Resident 3), when Resident 3 did not give informed consent for an antidepressant (medications used to treat major depressive disorder-severe mental health condition causing persistent sadness, hopelessness, and a loss of interest in activities) medication. This failure resulted in Resident 3 not being informed of potential side effects or complications and the ability to refuse treatment. During a review of Resident 3's Order Summary (OS), dated 4/28/26, the OS indicated Resident 3 had Venlafaxine (antidepressant) ordered for major depressive disorder. During a review of Resident 3's Psychotherapeutic Drug Informed Consent Forms (IC), there was no IC before 6/22/26 for Venlafaxine. During an interview on 6/25/26 8:37 a.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe smoking practices were implemented and monitored for one of 23 sampled residents (Resident 52) who used the designated smoking area. This failure placed Resident 52 and other residents who accessed the smoking area at risk for an uncontrolled fire and potential burns.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled Residents' (Resident 1) was free from accidents during incontinence care (the management and support for individuals with involuntary urine or stool leakage, aiming to maintain hygiene, skin health, dignity, and quality of life). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure for one of two sampled residents, (Resident 2) the Physician's Orders for Life Sustaining Treatment (POLST) was completed and the Do not Resuscitate physician order was followed during a medical emergency. This failure resulted in medical interventions for CPR (Cardiopulmonary Resuscitation - an emergency technique combining chest compressions and rescue breaths to maintain blood flow and oxygen to the brain and vital organs when someone's heart has stopped (cardiac arrest) and defibrillation (uses an electrical shock inside or outside the body to stop an abnormal heart rhythm in the heart's ventricles to allow the heart to start a normal rhythm again) on Resident 2 which were not requested. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the results of the investigations of an abuse allegation were reported timely to the State Agency (SA, which is the California Department of Public Health, CDPH), for one sampled resident (Resident 1) when Resident 1 alleged that staff was rough with him. This failure had the potential to compromise the safety of all residents in the facility from unreported investigations and results of the investigations. Review of Resident 1's admission record, undated, indicated that he was admitted on [DATE] with diagnoses that included diabetes, urine retention, and hyperlipidemia. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a homelike environment when three out of four sampled rooms (Room A, B, and C) were observed to have privacy curtains that were worn and frayed along the bottom and side edges, detracting from the homelike appearance of the resident rooms. This failure had the potential to negatively affect the residents' quality of life and homelike environment. During a concurrent observation and interview with Housekeeping Supervisor (HS) on 12/18/25 at 9:29 a.m., the bottom hems of the privacy curtains in room A and B were frayed with loose threads that were hanging down, and the fabric linings/nettings were exposed and detached near the lower edge. The side hem of the privacy curtain in room C appeared worn and frayed. The HS stated the curtains were torn and in need of replacement. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for 3 (Residents #24, #54, and #87) of 18 sampled residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to refer the resident to the appropriate state-designated authority for a level II preadmission screening and resident review (PASARR) evaluation once a resident was identified to have a new mental illness diagnosis for 1 (Resident #22) of 1 sampled resident reviewed for PASARR.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to assess a resident for the use of a bed rail for 2 (Resident #20 and Resident #34) of 4 sampled residents reviewed for accidents.

Inspectors wroteBased on interview, record review, and document review, the facility failed to provide timely follow up of medically related social services to obtain dental services related to the replacement of dentures for 1 (Resident #54) of 1 sampled resident reviewed for dental services.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to: implement enhanced barrier precautions for 1 (Resident #34) of 1 sampled resident reviewed for tube feeding; perform hand hygiene when gloves were removed during the provision of care for 1 (Resident #29) of 1 sampled resident reviewed for pressure ulcer/injury and 1 (Resident #34) of 1 sampled resident reviewed for tube feeding; and store respiratory equipment for 1 (Resident #24) of 4 sampled residents reviewed for respiratory care.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to address and make prompt efforts to resolve complaint allegation for one (Resident 1) of three sampled residents when facility did not thoroughly investigate and provide timely response to Resident 1 ' s allegation that Certified Nursing Assistant (CNA1) dragged and bumped his right foot into a wall while pushing him in wheelchair. This failure had the potential to cause Resident 1 emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure a licensed vocational nurse (LVN 1) administered medication accurately and safely to one of two sampled residents (Resident 1) according to the physician orders when Bengay cream (used to treat minor aches and pains of the muscles/joints) was administered instead of a skin barrier cream on Resident 1 ' s moisture associated skin damage (a form of incontinence-associated dermatitis, which is inflammation of the skin from extended exposure to urine or stool). This failure resulted in pain and discomfort for Resident 1.

Inspectors wroteBased on interview and record review the facility failed to ensure one resident (Resident 1) of three sampled residents received care to prevent the development of a pressure injury (damage to skin because of continuous pressure) when Resident 1 developed a Stage 3 pressure injury on the sacrococcygeal (the area between the hip bone on person ' s back and the tailbone) region. This failure resulted in Resident 1 obtaining a facility acquired Stage 3 pressure injury (the loss of skin which extends to the tissue beneath the skin).

Inspectors wroteBased on interview and record review, the facility failed to develop Baseline Care Plan (BCP) and provide written summary of the care plan to resident (s) and /or resident's representative for 31 of 31 sampled residents (Residents 9, 22, 28, 31, 43, 73, 74, 77, 281, 431, 180, 280, 430, A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, P, Q and R) when: 1. For Resident 9, 22, 28, 31, 34, 73, 74, 77, 281, 431, K, L, M, N, O, P, Q and R's BCP for dietary, therapy and social services were not developed within 48 hours of admission. There was no evidence a copy of the BCP summary was provided to the resident or resident's representative. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen staff were competent in job duties related to 1. Testing the sanitizer liquid in the red sanitization bucket. 2. Using the three compartment sink This failure has the potential for improper cleaning and sanitization which could lead to increase in risk for food-borne illness for 82 out of 82 residents.

Inspectors wroteBased on observation, interview, and record review, facility failed to provide palatable food when food was served bland (lacking flavor). This failure has the potential for 82 out of 82 residents to consume less food resulting in consumption of less calories and nutrients provided by the planned menu. Findings During a review of the Diet Extensions dated Tuesday, Week 3, [NAME] SS 2023 and used for lunch on 6/27/23, the Diet Extension indicated, the regular consistency food included Baked Pork Chop, Cornbread Dressing, and Squash Medley. The Minced and Moist food included minced and moist pork chop, pureed cornbread dressing, and minced and moist squash medley. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food safely when 1. Kitchen staff did not follow approved hand hygiene and glove use procedures when changing gloves 2. 7 clear containers of various powders, 18 servings of frozen dessert, and one bag of green lettuce was not dated and labeled. These failures have the potential of placing 82 out of 82 residents at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 56 and Resident 62) received finger nail care. Resident 56 and Resident 62 had long, thick fingernails with black matter underneath in both hands. This failure placed Resident 56 and Resident 62 at risk for infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to trim and clean toenails for one of one sampled resident (Resident 62). Resident 62's both great toenails were dark yellow-brown, thick, curved-in and long about one inch in length. This failure resulted in Resident 62 to not receive toenail care for three months, placed Resident 62 at risk to get toenails yeast infection and dislocate her both great toenails.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide upper and lower body Range of Motion (ROM) and walking exercises to one of three sampled residents (Resident 65) per plan of care. Resident 65 received walking exercises for four (4) out of 12 scheduled visits and upper/lower body ROM exercises for three (3) out of 12 scheduled visits over a period of one month. This failure had the potential to result in Resident 65 feeling not receiving good care and placed her at risk for further decreased in limitation of (ROM) and walking.