Stonebridge Marble Hill

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF689Feb 9, 2023

  Based on observation, record review and interviews, the facility failed to ensure all residents were kept free from possible accident hazards when the facility staff failed to monitor one resident (Resident #12) outside the sample for self administration of dietary supplements bought on the Internet and for giving the same supplements to another resident (Resident #49) out of a sample of 18. The facility census was 73. Record review of the facility policy titled Medications Brought to the Facility by the Resident/Family, revised April 2007, showed: -The facility shall ordinarily not permit residents and families to bring medications into the facility; -Residents and families must report to the nursing staff any medications that they want to bring, or have brought into the facility; -The… […]

• No harm, potential for more than minimal, patternF880Feb 9, 2023

  Based on observation, interview and record review, the facility failed to utilize proper technique during incontinent care for one resident (Resident #3) when staff touched the trash can during care and dropped the box of wipes on the floor three times. Staff did not change gloves, perform hand hygiene after touching the trash can and the box of wipes that he/she picked up from the floor. During wound care staff failed to use a barrier for supplies, disinfect the bandage scissors, used for multiple residents, before and after use, and perform appropriate hand hygiene and glove changes for one resident (Resident #14), outside of 18 sampled residents. […]

• No harm, potential for more than minimal, isolatedF552Jan 8, 2026

  Based on interview and record review, the facility failed to ensure informed consent was obtained and documented for the use of psychotropic (a medication that affects brain activities associated with mental processes and behavior) medications for three residents (Residents #8, #10, and #61) out of six sampled residents. This failure prevented the resident and/or their representative from knowing the risks and the benefits of using psychotropic medications. The facility census was 71. […]

• No harm, potential for more than minimal, isolatedF605Jan 8, 2026

  Based on interview and record review, the facility failed to attempt a gradual dose reduction (GDR) for psychotropic (medications that affect how the brain works and causes changes in mood, awareness, thoughts, feelings, or behaviors) medications for two residents (Residents #7 and #10) out of five sampled residents. The facility census was 71. Review of the facility policy titled, Psychotropic Medication Use, dated October 2017, showed: - Psychotropic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review; - The physician shall respond appropriately by changing or stopping problematic doses or medications or clearly documenting why the benefits of the medication outweigh the risks or suspected or… […]

• No harm, potential for more than minimal, isolatedF628Jan 8, 2026

  Based on interview and record review, the facility failed to provide required written notice and documentation related to discharge and bed hold policy requirements, including the required daily bed hold rate for four residents (Residents #1, #3, #13, and #70) out of four sampled residents. The facility also failed to complete a recapitulation of stay upon discharge to home for one resident (Resident #72) out of two closed records reviewed. The facility census was 71.Review of facility policy titled, Bed Holds, dated March 2022, showed: - Upon admission and when a resident is transferred for hospitalization or for therapeutic leave, the facility will provide information regarding the bed hold policy to the resident or representative in a written format that is understood by the resident or… […]