Stonebridge Desoto

In the surveyor’s words

From the most serious findings on record at Stonebridge Desoto, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 24, 2025

  Based on interview and record review, the facility failed to ensure the safety of one resident (Resident #1) out of three sampled residents when staff failed to place a fall mat next to the resident's bed as directed by the care plan. The resident fell out of bed onto the floor resulting in injury. The facility census was 52. The administration was notified on 07/24/25 of the Past Non-Compliance which occurred on 07/18/25. On 07/18/25, upon notification, the facility administration started an investigation and notified the Department of Health and Senior Services of the fall which resulted in a fracture. […]

• No harm, potential for more than minimal, patternF812Feb 9, 2024

  Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices affected all residents. The facility census was 46. Review of the facility's Food Receiving and Storage policy, revised July 2014, showed: - Foods shall be received and stored in a manner that complies with safe food handling practices; - All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). 1. Observation on 02/06/24 at 10:46 A.M. […]

• No harm, potential for more than minimal, patternF812Aug 5, 2022

  Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents. The facility census was 46. 1. Observations of the kitchen on 8/2/22 10:58 A.M., showed: - Ice machine drain pipe with an air gap set at one inch (in) near the floor drain and the pipe covered in black grime; - Ice machine drain pipe not aligned over the floor drain and water dripped on the floor; - Walk in refrigerator door drug the floor and loose at the hinges; - Walk in freezer temperature of 4 degrees Fahrenheit with some large ice formed on the refrigeration lines; - Ice formed on food boxes under the fan in the back of the freezer… […]

• No harm, potential for more than minimal, patternF880Aug 5, 2022

  Based on observation, interview, and record review, the facility failed to maintain infection control practices for four sampled residents (Residents #20, #21, #28, and #37) and three residents outside of the sample (Residents #8, #11, and #14) during medication administration when facility staff did not wash or sanitize their hands during medication administration. The facility staff also failed to follow appropriate infection control practices when staff administered a medication to a resident (Resident #11) that fell on the resident's chest and staff picked the medication up with his/her bare hand and administered it. Staff also did not wear gloves during insulin (a hormone injected just under the skin to lower blood sugar) administration. The facility's census was 46. […]

• No harm, potential for more than minimal, isolatedF628Jun 26, 2026

  Based on interview and record review, the facility failed to provide written notice of transfer to the resident and/or the resident's representative that included all required transfer information, including bed-hold information for six residents (Residents #3, #10, #16, #34, #36 and #40) out of six sampled residents who were transferred to the hospital. The facility census was 49. Review of the facility's policy titled, Bed Holds, dated March 2022, showed: The facility would inform residents upon admission and prior to a transfer for hospitalization or therapeutic leave of the bed-hold policy; Upon admission and when a resident transferred for hospitalization or therapeutic leave, the facility would provide written information regarding the bed-hold policy to the resident or… […]