Stonebridge Oak Tree

In the surveyor’s words

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

• Actual harm, isolatedF580Apr 18, 2024

  Based on interview and record review, facility staff failed to notify one resident's (Resident #1's) out of one sampled residents family and physician when a resident leg fell from the wheelchair pedal which resulted in a fracture to the residents leg. The facility census was 26. 1. Review of the facility Change in a Resident's Condition or Status policy, revised May 2017, showed the facility shall promptly notify the residents attending physician and representative of changes in the resident medical/mental condition and/or status. Review showed the nurse will notify the resident's attending physician or physician on call when there is an accident or incident involving the resident. […]

• No harm, potential for more than minimal, widespreadF812May 1, 2026

  Based on observation, interview and record review, the facility staff failed to maintain an air gap (a safety feature which prevents sewage from backing up into ice machines) for two of two ice machine drains. This failure has the potential to affect all residents. The facility census was 34. 1. Review of the facility's policies provided showed they did not contain a policy related to ice machine air gaps. Observation on 04/29/26 during the Life Safety Code tour showed the black drain hose from the kitchen ice machine on the floor in a small puddle of water near the floor drain which did not have a cover and had an accumulation of black material. […]

• No harm, potential for more than minimal, widespreadF812Feb 28, 2025

  Based on observation, interview and record review, the facility staff failed to store food in a manner to prevent contamination and out-dated use. Facility staff failed to perform hand hygiene as often as necessary, using approved techniques, to prevent cross-contamination. Facility staff failed to allow sanitized dishes to air dry prior to stacking in storage to prevent the growth of foodborne pathogens. The facility census was 30. 1. Review of the facility's Food Safety Requirements policy, dated September 2022, showed: -Food safety practices shall be followed throughout the facility's entire food handling process. […]

• No harm, potential for more than minimal, widespreadF814Feb 28, 2025

  Based on observation, interview and record review, the facility staff failed to properly contain waste and refuse to prevent the harboring and/or feeding of rodents and pests when the facility failed ensure indoor and outdoor waste containers remained covered when not in actual use. This failure has the potential to affect all facility occupants. The facility census was 30. 1. Review of the facility's Infection Prevention and Control-Maintenance Department policy, dated 2017, showed infection prevention and control measures included waste processing systems, including dumpsters, trash bins, incinerators and et cetera. Review showed the policy directed staff to: -Enforce proper bagging and containment of waste. […]

• No harm, potential for more than minimal, widespreadF812Nov 22, 2023

  Based on observation, interview and record review, the facility staff failed to perform hand hygiene as often as necessary, using approved techniques, to prevent cross-contamination. Facility staff failed to ensure hair coverings remained in place during the service of resident meals to prevent the potential for food contamination. Facility staff failed to maintain kitchen equipment and surfaces in a clean sanitary manner to prevent the potential for cross-contamination. Facility staff failed to store food in a manner to prevent contamination and out-dated use. Facility staff failed to ensure the dish washing machine functioned properly before using it to sanitize kitchen wares. The facility census was 30. 1. […]