Stonebridge Health Campus

In the surveyor’s words

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

• Actual harm, isolatedF760Dec 6, 2022

  Based on observation, interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 3 residents reviewed for medication administration. This resulted in the resident requiring admission to the hospital intensive care unit. (Resident 45). Finding includes: During an interview on 11/30/22 at 1:42 p.m., Resident 45 indicated over a month ago, she had received Resident 46's medication. A nurse came into her room with two medication cups which had their names on them. The nurse administered her (Resident 45) Resident 46's medication. Later that evening, the facility rushed her to the hospital. On 12/2/22 at 11:19 a.m., Resident 45's clinical record was reviewed. […]

• No harm, potential for more than minimal, patternF921Dec 20, 2021

  Based on observation, interview, and record review, the facility failed to ensure residents' transfer equipment was free from disrepair for 14 of 54 residents reviewed for transfer equipment status (Residents 8, 32, 40, 102, 44, 21, 103, 15, 10, 7, 17, 43, 36, and 4) and failed to ensure residents' bedroom furniture was free from disrepair for 2 of 24 residents reviewed environment (Residents 6 and 20). Findings include: During a facility tour, on 12/20/21 at 11:00 a.m., the following was observed: 1a.) Resident 8's wheelchair back and bottom cushion were observed to have multiple cracks in the outer layer. 1b.) Resident 32's left armrest was observed to have multiple cracks. 1c.) Resident 40's wheelchair back was observed with multiple cracks. […]

• No harm, potential for more than minimal, isolatedF628Jul 14, 2026

  Based on interview and record review, the facility failed to ensure the Notice of Transfer or Discharge and Bed hold Policy was provided to the residents or the resident's representative when transferred to the hospital for 2 of 4 residents reviewed for hospitalization. (Resident 11, Resident 68) Findings include: On 7/13/26 at 9:55 a.m., Resident 11's clinical record was reviewed. The diagnoses included, but were not limited to, stroke and anxiety. A progress note, dated 4/13/26 at 10:51 p.m., indicated Resident 11 fell while sitting in the wheelchair. […]

• No harm, potential for more than minimal, isolatedF636Sep 18, 2025

  Based on interview and record review, the facility failed to complete a comprehensive assessment of a resident within 14 calendar days after admission to the facility for 1 of 1 residents reviewed for assessments. (Resident 59)Findings include:On 9/17/25 at 10:27 a.m., Resident 59's clinical record was reviewed. The diagnoses included, but were not limited to, chronic kidney disease, COPD (chronic obstructive disease), and chronic respiratory failure. The resident was admitted on [DATE]. A 9/4/25 admission Minimum Data Set (MDS) assessment was completed on 9/14/25. This was 4 days after day 14. During an interview on 9/17/25 at 11:36 a.m., the Corporate Nurse Consultant indicated the MDS assessment was completed late. […]

• No harm, potential for more than minimal, isolatedF644Sep 18, 2025

  Based on interview and record review, the facility failed to ensure a PASARR (preadmission screening and resident review) was completed when a new mental health diagnosis was added for 1 of 5 residents reviewed for unnecessary medications. (Resident 7)Findings include:On 9/17/25 at 11:30 a.m., Resident 7's clinical record was reviewed. The diagnoses included, but were not limited to, new diagnosis on 4/12/25 of schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia and a mood disorder), dementia (loss of memory, language, problem-solving and other thinking abilities), brief psychotic disorder (mental health condition characterized by sudden, short-lived psychotic symptoms, that last for at least one day but less than one month), major depressive… […]