Stone Bridge Center for Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Stone Bridge Center for Health & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF600Jan 26, 2023

  Based on observations, clinical record reviews, facility documentation review, facility policy review, and interviews for 18 of 18 residents (Resident #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17 and 18) reviewed for care and services, the facility failed to ensure the needs of all residents were met timely, in accordance with their plan of care resulting in neglect. The failures to provide care as required resulted in a finding of Immediate Jeopardy. The findings include: 1. Resident #1's diagnoses included cerebrovascular disease, diabetes, urinary tract infection, Alzheimer's disease, and dementia. […]

• Immediate jeopardy, patternF725Jan 26, 2023

  Based on observations, clinical record reviews, facility documentation review, facility policy review, and interviews for 20 of 23 residents (Resident #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 22, and 23) reviewed for assistance with activities of daily living, the facility failed to ensure adequate staffing levels to ensure resident care and services were provided timely. The failures resulted in a finding of Immediate Jeopardy. The findings include: 1. Resident #1's diagnoses included cerebrovascular disease, diabetes, urinary tract infection, Alzheimer's disease, and dementia. […]

• Actual harm, isolatedF689Jun 2, 2025

  Based on review of clinical records, review of facility documentation, review of facility policy and interviews for two of four sampled residents (Resident #61 and #228) reviewed for accidents, the facility failed to ensure the wheelchair leg rests were in place during transport, which resulted in an accident and failed to ensure the resident was transferred as ordered with assist of one and the utilization of a walker, which resulted in a right lower leg laceration sustained as a result of the improper transfer from the wheelchair to the bed. The findings include: 1. […]

• Actual harm, isolatedF600Mar 21, 2023

  Based on review of the clinical record, facility documentation, facility policy, and interviews for one of six residents (Resident #81) reviewed for abuse, the facility failed to ensure adequate supervision for a resident with a history of wandering to prevent the resident from getting into another resident's bed, and for one of six residents reviewed for abuse (Resident #39) the facility failed to ensure the resident was free from verbal abuse by a staff member. The findings include: 1. a. Resident #81 was admitted to the facility to unit 2B (second floor), with diagnoses that included dementia and cognitive communication deficit. […]

• Actual harm, isolatedF689Apr 23, 2021

  Based on review of the clinical record, observations, interviews, and review of facility documentation, for three of six residents (Resident # 296) reviewed for accidents, the facility failed to ensure the resident was transferred via mechanical lift with two staff members in accordance to the plan of care and for one of three residents (Resident # 89) reviewed for elopement the facility failed to prevent and elopement . The findings included: 1. Resident #296's diagnoses included dementia, difficulty walking, and abnormality of gait, fracture of left femur following insertion of implant or prosthesis, and weakness. […]