Stonebrook Post Acute

In the surveyor’s words

From the most serious findings on record at Stonebrook Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 23, 2026

  Based on observation, interview, and record review, the facility failed to ensure one of three sampled Residents' (Resident 1) was free from accidents during incontinence care (the management and support for individuals with involuntary urine or stool leakage, aiming to maintain hygiene, skin health, dignity, and quality of life).This failure resulted in Resident 1 falling out of bed and sustaining a bruise (discolored skin on the body, caused by a blow or impact rupturing underlying blood vessels) to the forehead, perinasal hematoma (accumulation of blood within the nasal septum, which is the wall of cartilage and bone that divides the two nostrils), right elbow abrasion (a superficial, minor injury where the top layer of skin is scraped or rubbed away), and right femoral fracture (a… […]

• Actual harm, isolatedF656Mar 5, 2024

  Based on interview and record review the facility failed to initiate and implement person-centered care plans for one resident (Resident 1) of three sampled residents when the facility: 1. Did not initiate a care plan when Resident 1 obtained Moisture-Associated Skin Damage (MASD); 2. Did not implement interventions to prevent Resident 1 from obtaining a pressure injury (damage to skin because of continuous pressure); and, 3. Did not initiate a care plan when Resident 1 obtained a facility acquired Stage 3 pressure injury on the sacrococcygeal (the area between the hip bone on a person ' s back and the tailbone) region. These failures resulted in Resident 1 obtaining a facility acquired Stage 3 pressure injury (the loss of skin which extends to the tissue beneath the skin). Findings: 1. […]

• Actual harm, isolatedF658Mar 5, 2024

  Based on interview and record review the facility failed to ensure care provided met professional standards of care for one resident (Resident 1) of three sampled residents when: 1. Nursing staff did not weigh Resident 1 per physician ' s orders; 2. Nursing staff did not get Resident 1 out of bed as ordered by the physician; 3. Nursing staff did not implement or initiate care plans as Resident 1 ' s wound continued to worsen; and, 4. There was no oversight of Resident 1 ' s worsening wound on the sacrococcygeal region (the backside area between a person ' s hips and down to the tailbone). This failure resulted in Resident 1 obtaining a facility acquired Stage 3 pressure injury (the loss of skin which extends to the tissue beneath the skin). Findings: 1. […]

• Actual harm, isolatedF686Mar 5, 2024

  Based on interview and record review the facility failed to ensure one resident (Resident 1) of three sampled residents received care to prevent the development of a pressure injury (damage to skin because of continuous pressure) when Resident 1 developed a Stage 3 pressure injury on the sacrococcygeal (the area between the hip bone on person ' s back and the tailbone) region. This failure resulted in Resident 1 obtaining a facility acquired Stage 3 pressure injury (the loss of skin which extends to the tissue beneath the skin). […]

• Actual harm, isolatedF689Nov 9, 2021

  Based on observation, interview, and record review, the facility failed to implement a fall prevention precaution for one of three residents (Resident 1) when there was no fall mattress (a padded floor mat) placed adjacent to Resident 1's bed to decrease the chance of injury from falls as indicated in the care plan. This failure resulted in Resident 1 receiving emergency room treatment after he sustained a laceration (a skin cut) above his left eyebrow, bruising of his left cheek, and a broken hip prosthesis (an artificial, surgical implant replacing the original body part) after he fell from his bed onto the floor. […]