Stonebridge at Montgomery Health Care Center

In the surveyor’s words

From the most serious findings on record at Stonebridge at Montgomery Health Care Center, in the surveyor’s own words.

• Actual harm, patternF689Jun 25, 2025

  Based on observation, interview, record review, and review of pertinent documents, it was determined that the facility failed to: a.) adequately monitor and supervise a resident (Resident #15) who was identified as a high fall risk and sustained nine unwitnessed falls with four falls that resulted in injuries that required hospitalization which included; an intracranial bleed (brain injury) and a laceration that required seven sutures (stitches), a fracture to the left hip requiring surgical repair (Open Reduction and Internal Fixation - ORIF), a hematoma (collection of blood outside the blood vessels similar to a bruise) and laceration to the back of the head that was closed with stitches, and a right hip fracture; b.) revise, reassess, and re-evaluate a resident (Resident #21) who had a… […]

• Actual harm, isolatedF686Jun 25, 2025

  Complaint #: NJ 175572 Based on interview, record review and review of facility documents, it was determined that the facility failed to ensure that a resident who did not have a Pressure Ulcer (PU) upon admission and who was identified at risk of developing a PU, received care and services in accordance with professional standards of practice to prevent PUs. Resident # 147 developed a facility aquired Stage 3 left hip PU that was identified during an outpatient (outside) wound care physician visit/consult on 5/22/24. This deficient practice was identified for 1 of 1 resident (Resident #147) reviewed for wound care and was evidenced by the following: The surveyor reviewed the closed Medical Record (MR) for Resident #147. […]

• Actual harm, isolatedF689Sep 9, 2021

  Based on observation, interview, record review, as well as a review of pertinent facility documents, it was determined that the facility failed to ensure that a resident was transferred using the correct mechanical lift device and utilized the sufficient required staff assistance to prevent accidents and injury for 1 of 3 residents reviewed; (Resident #14). On 6/23/21, Resident #14 was improperly transferred by 1 staff instead of 2, which resulted in significant bruising on the left axillary region, a left chest wall hematoma (a collection of blood outside of the vessels caused by an injury to the wall of the blood vessel, prompting blood to seep out of the vessel into the surrounding tissues) and complaints of pain that resulted in emergency room services and hospitalization . […]

• No harm, potential for more than minimal, widespreadF812Jul 7, 2026

  Repeat Deficiency Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 6/25/26 at 9:19 AM, in the presence of the Director of Culinary (DOC) the surveyor observed the following:1. On the bread storage shelf, the surveyor observed an opened bag of sandwich rolls without an opened or use by label. The DOC stated all opened items should be labeled with a use by label.2. On the dry storage shelf, the surveyor observed a 42-ounce (oz) container of oatmeal with a use by date of 6/1/26. The DOC stated the oatmeal should have been discarded.3. […]

• No harm, potential for more than minimal, widespreadF812Jun 25, 2025

  Based on observation, interview and document review it was determined that the facility failed to store food in a sanitary manner, and maintain the kitchen equipment and environment in a clean and sanitary manner to prevent contamination from foreign substances and the potential for the development of food borne illness. This deficient practice affected all residents who resided at the facility, and was evidenced by the following: On 6/16/25 at 8:17 AM, the surveyor conducted an initial tour of the kitchen in the presence of the Assistant Director of Dining (ADD) and observed the following: 1. The white ceiling tiles in the food preparation area had visible debris affixed to the tiles and dust like debris on the ceiling vents. The ADD stated, I can see it. 2. […]