Stonebrooke Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Stonebrooke Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF600Jun 17, 2026

  Based on interview and record review, the facility failed to ensure a resident was free from mental abuse by a staff member obtaining a photograph of the resident's genitalia without the resident's permission and showing other staff members resulting in unauthorized photographs taken for 1 of 4 residents reviewed for abuse. (Resident B) Using the reasonable person concept, it is likely this would lead to humiliation, confusion, anxiety, and embarrassment for Resident B. Findings include:The clinical record for Resident B was reviewed on 6/12/26 at 10:26 a.m. […]

• No harm, potential for more than minimal, widespreadF812Mar 22, 2024

  Based on observation, interview, and record review, the facility failed to ensure to maintain a clean, sanitary kitchen, ensure the holding refrigerator didn't contain unlabeled and/or expired foods, ensure bread was discarded that contained a fuzzy green, yellow substance, and ensure a cup was not present in the bulk storage bin. This had the potential to affect all 72 residents who receive food from the kitchen. Findings include: A kitchen tour was conducted on [DATE] at 10:45 a.m. with Cook 2. The holding fridge had a container of diced ham with a date of [DATE] and a use by date of [DATE]. Cook 2 indicated she wasn't sure why they would make the use by date 10 days after the preparation date. The date was usually 7 days after the preparation date. […]

• No harm, potential for more than minimal, widespreadF812Jan 24, 2023

  Based on observation, interview, and record review, the facility failed to ensure temperature logs were completed and the sanitizing solution was tested for a chemical dishwasher that resulted in lack of sanitizing solution being distributed for an unknown period of time. This had the potential to affect all 78 residents that receive food from the kitchen. Findings include: An observation of the kitchen was conducted on 1/18/23 at 10:30 a.m. Culinary Assistant (CA) 11 was proceeding to run dirty dishes through the dishwasher. CA 11 indicated the machine was a chemical dishwasher. The dial registered the temperature to be 138 degrees. She took a testing strip for the sanitizing solution and the strip did not change color to indicate the presence of a chemical sanitizing solution. […]

• No harm, potential for more than minimal, patternF921Mar 22, 2024

  Based on observation, interview, and record review, the facility failed to ensure resident rooms were in good repair related to the walls, headboard, and cove base (soft flexible material along the bottom part of the wall) in a bathroom for 6 of 72 residents reviewed for environment. (Resident 283, 40, 18, 44, 11, and 28) Findings include: An observation conducted on 3/19/24 at 9:38 a.m. noted Resident 283's room with the cove base peeling in the bathroom. An observation conducted on 3/18/24 at 12:23 p.m. noted Resident 40's room with missing paint alongside the wall behind the headboard. An observation conducted on 3/18/24 at 12:34 p.m. noted Resident 18's room with missing paint and drywall behind the headboard. An observation conducted on 3/19/24 at 9:46 a.m. […]

• No harm, potential for more than minimal, patternF584Jan 24, 2023

  Based on observation, interview, and record review, the facility failed to maintain clean tables in the activity/dining room on the locked unit. This affected all 19 residents who used the activity/dining room. Findings include: On 1/20/23 at 2:03 p.m., the six square tables in the activity/dining area were observed to have a build up of a brown, gummy substance around all the edges. There were six square tables and one rectangle table. The rectangle table is wooden and the wooden legs were scuffed and marred. On 1/23/23 at 3:14 p.m., the dining room/activity room was observed to have six square tables and one rectangle table. The square tables have a metal stand in the center of the table to the floor with 4 supports that come out from the metal pole. […]