Stonebridge Health & Rehabilitation Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF658Jun 11, 2026

  Based on observations, clinical record review, review of facility documents, and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of 18 residents reviewed (Resident 11). Findings Include: Review of Resident 11's clinical record revealed diagnoses that included COPD (chronic obstructive pulmonary disease- a progressive, inflammatory lung disease that blocks airflow and makes breathing difficult) and anxiety. During an interview with Resident 11 on June 8, 2026, at 10:34 AM, Resident 11 stated that she was missing her left hearing aid. Observation of Resident 11 at that time revealed she did not have a hearing aid in either ear. […]

• No harm, potential for more than minimal, patternF880Jul 2, 2025

  Based on observations, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to maintain an effective infection control program related to the preparation and administration of medications for two of two residents observed; failed to ensure staff implemented infection control policies to prevent the spread of infection for one of 19 residents reviewed; and failed to maintain an accurate data collection system of infection surveillance from October 2024 through March 2025. […]

• No harm, potential for more than minimal, patternF755Apr 10, 2025

  Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to provide routine drugs and biologicals to its residents and provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for three of seven residents reviewed (Residents 1, 2, and 3). Findings include: Review of facility policy, titled Delivery and Receipt of Routine Deliveries subsection Long-Term Care Facilities Receiving Products and Services from Pharmacy last revised August 1, 2024, read, in part, Receipt of Medications and Supplies: A facility nurse should inspect the package(s) for any damage or errors and notify pharmacy as… […]

• No harm, potential for more than minimal, patternF606Aug 11, 2022

  Based on employee record review, facility policy review, and staff interview, it was determined that the facility failed to ensure a thorough screening of new hires was completed for five of five staff members reviewed (Employees 1, 2, 3, 4, and 5). Findings include: Review of facility policy (not titled), last reviewed July 2022, revealed section, Procedure subsection 1. Screening, stated, [the] facility will not employ or otherwise engage individuals who have been found guilty of abuse, neglect, or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF623Aug 11, 2022

  Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident/resident representative and the representative of the Office of the State Long-Term Care Ombudsman of resident transfers, in writing, to include the following: the reason for the transfer or discharge, date of transfer, location of transfer, statement of the resident's appeal rights, and name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman for three of 18 resident records reviewed (Residents 23, 34, and 47). Findings include: Review of Resident 23's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]