Stonebrook Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Stonebrook Health and Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Aug 1, 2025

  Based on observation, interview, and record review, the facility failed to ensure proper drying of cooking/serving equipment, when a large baking pan and three steam table pans were stacked while still wet. This failure had the potential to cause foodborne illness (illness resulting from contaminated food) for 67 residents who received food from the kitchen. Findings:During an initial inspection of the kitchen, 1 large baking pan was observed wet in the stack of baking pans that had been put away for storage, 1 steam table pan in a stack of steam table pans which had been put away for storage, and three other steam table pans in a different stack of steam table pans which had been put away for storage.During an interview with the dietary manager (DM) on 7/28/25 at 8:53 a.m., he… […]

• No harm, potential for more than minimal, patternF732Dec 29, 2025

  Based on observation, interview, and record review, the facility failed to ensure to post the daily staffing information daily. This failure had the potential to result in nurse staffing misinformation to residents, families, and visitors.Findings: During an observation on 12/29/25 at 9 a.m., the Census and Direct Care Service Hours Per Patient Day (DHPPD-a form containing daily staffing information) form dated 12/10/25 (19 days past) was posted in the hallway next to the facility's entrance lobby. During an interview and observation with licensed vocational nurse (LVN) A on 1/29/25 at 9:16 a.m., LVN A confirmed the observation. […]

• No harm, potential for more than minimal, patternF700Aug 1, 2025

  Based on observation, interview, and record review, the facility failed to ensure that alternatives were attempted and documented prior to using side rails (devices attached to the side of a bed) for 32 of 68 sampled residents (Residents 1, 4, 6, 12, 16, 17, 18, 25, 26, 31, 32, 33, 43, 48, 50, 51, 56, 59, 70, 82, 83, 84, 86, 87, 88, 89, 93, 94, 95, 96, 100, and 101) reviewed for side rail use.Findings:During multiple observations on 7/28/25 between 9:00 a.m. and 3:00 p.m., Residents 1, 4, 6, 12, 16, 17, 18, 25, 26, 31, 32, 33, 43, 48, 50, 51, 56, 59, 70, 82, 83, 84, 86, 87, 88, 89, 93, 94, 95, 96, 100, and 101 were observed with both upper side rails raised.Review of the Alternative Measures Tried section on the facility's Siderails Screening Tool showed no evidence that alternatives were… […]

• No harm, potential for more than minimal, patternF880Aug 1, 2025

  Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program to prevent the spread of infections as evidenced by:1. Licensed nurses did not know the process to disinfect a glucometer (blood glucose meter to measure and display the amount of sugar [glucose] in your blood) according to manufacturer's instructions;2. Resident 52's urinary catheter bag (a bag that is attached to a tube that is connected to the bladder) was touching the floor; and3. The Certified Nursing Assistant (CNA) did not perform hand hygiene after removing her gloves and prior handling the new clean bed linens.These failures had the potential to compromise resident's health and safety in the facility.1. […]

• No harm, potential for more than minimal, patternF658Aug 6, 2021

  Based on observation, interview and record review, the facility failed to provide care and services in accordance with professional standards of practice when: 1. For Resident 201, the daily weight and the fluid restriction orders were not followed; 2. For Resident 204 the PICC line external catheter length was not measured during each dressing change and flushes were not performed; 3. For Resident 217, dressing changes and flushes were not performed for the PICC line; 4. For Resident 2, physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] 5. For Resident 249, the PICC line external catheter was not measured upon admission and during dressing change; 6. For Resident 46, the left hemi arm tray use was not followed. 7. […]