Stonebridge Owensville

In the surveyor’s words

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

• Actual harm, isolatedF689Nov 26, 2025

  Based on observation, interview, and record review, facility staff failed to safely transfer one resident (Resident #1) out of two sampled residents in a manner to prevent accidents when staff failed to use a gait belt during a transfer which resulted in a fracture. The facility's census was 73. The administrator was notified on 11/26/25 of past Non-Compliance which occurred on 11/16/25 when the administrator implemented new policies and procedures to ensure the nursing staff safely transferred residents. Staff were in-serviced on 11/16/25 regarding how to safely transfer a resident.1. […]

• Actual harm, isolatedF689Apr 8, 2025

  Based on interview and record review facility staff failed to ensure one resident (Resident #1) remained free from accidents when staff failed to prevent Resident #1 from ingesting Resident #2's medications. The facility census was 83. The administrator was notified on 04/08/25 of past Non-Compliance which occurred on 03/29/25. when Resident #1 ingested Resident #2's medications. Staff assessed the resident, and notified the required parties and agencies. The administrator immediately in-serviced all nursing staff in-serviced nursing staff on medication administration. Staff corrected the deficient practice on 4/02/25. 1. […]

• No harm, potential for more than minimal, widespreadF801Mar 26, 2026

  Based on interview and record review, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. This failure has the potential to affect all residents. The facility census was 72.1. Review of the facility's policy titled Food Services Manager, updated 09/28/22, showed the Food Services Manager may serve as the Director of Food and Nutrition Services who must at a minimum meet one of the following qualifications:-A certified dietary manager (CDM), or;-A certified food service manager, or;-Has similar national certification for food service management and safety from a national certifying… […]

• No harm, potential for more than minimal, widespreadF812Mar 26, 2026

  Based on observation, interview and record review, the facility staff failed to ensure the mechanical dishwasher operated according to manufacturer's instructions in a manner adequate to prevent cross-contamination of kitchen wares. This failure has the potential to affect all residents. The facility census was 72.1. Review of the facility's policy titled Dishwashing Machine Use, revised March 2010, showed: -The operator will check temperatures using the machine gauge with each dishwashing machine cycle, and will record the results in facility approved log;-The operator will monitor the gauge frequently during the dishwashing machine cycle. […]

• No harm, potential for more than minimal, widespreadF880Aug 29, 2024

  Based on observation, interview, and record review, facility staff failed to provide a clean barrier for wound supplies during wound care for two residents (Resident #2 and #3) and failed to perform approved hand hygiene during incontinence care for two residents (Resident #3 and #64) out of 25 sampled residents. Facility staff failed to ensure dietary staff performed hand hygiene as often as necessary using approved techniques to prevent cross-contamination during food preparation and service. The facility census was 71. 1. Review of the facility's policy titled, Dressings, Dry/Clean, dated September 2013, showed staff are directed to do: -Clean bedside stand; -Establish a clean field; -Place clean equipment on the clean field. 2. […]