Stonebridge Westphalia

In the surveyor’s words

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

• Actual harm, isolatedF689Oct 12, 2023

  Based on observation, interview, and record review, facility staff failed to transfer three residents (Residents #1, #2 and #3) in a safe manner, when staff did follow the facility's policy and procedures for the mechanical lift, which resulted with one resident (Resident #1) with fracture of facial bones and laceration of the head. The facility census was 50. 1. Review of the mechanical lift owner's manual, dated June 2015, showed staff are to move lift so that it is positioned directly over the individual and utilize leg opening function if required. Attach the straps of the sling to the hooks of the carry bar. […]

• Actual harm, isolatedF689Aug 17, 2022

  Based on interview, and record review, facility staff failed to administer medication in a safe manner to prevent accidents for one resident (Resident #1) when they did not remove a [MEDICATION(S)] patch (medication used to treat nausea and/or vomiting) from his/her medication cup before he/she swallowed it and required an emergent transfer to the hospital. The facility census was 58. 1. Review of the facility's Administering Medications, Storage of Medications Policy, dated December 2012, showed medications must be administered in accordance with the orders and the individual administering the medication must check to verify the right route before the medication is administered. 2. […]

• No harm, potential for more than minimal, widespreadF880Jul 24, 2025

  Based on observation, interview, and record review, facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD) (a serious type of pneumonia (lung infection) caused by Legionella bacteria, which places all residents at risk of exposure which could lead to illness.The facility census was 54 with a capacity of 64.1. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17, showed:-The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. […]

• No harm, potential for more than minimal, widespreadF761May 9, 2024

  Based on observation, interview, and record review, staff failed to ensure medications were stored in a safe and effective manner, when staff failed to ensure medications were properly labeled and contained in their original package until time of administration on two medication carts. Staff failed to ensure multi-dose medications were dated when opened. Staff failed to discard expired medications in one medication room. Staff failed to store time scheduled controlled medications (drug or other substance that may cause addiction) in a separately locked, permanently affixed compartment. The facility census was 50. 1. […]

• No harm, potential for more than minimal, widespreadF880May 9, 2024

  Based on observation, interview, and record review, facility staff failed to perform appropriate hand hygiene, and glove changes during incontinence care for two (Resident #19 and #21) out of two sampled residents. Facility staff failed to perform appropriate hand hygiene, and glove changes during catheter care for one (Resident #4) out of one sampled resident. Facility staff failed to appropriately sanitize a multi-use glucometer (a device for monitoring blood sugars) between use for two residents (Resident #19 and #28) out of four sampled residents to prevent the spread of infection causing contaminants. The facility census was 50. 1. […]