Stonehill Care Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF880Aug 7, 2025

  Based on observation, clinical record review, staff interview, and facility policy review the facility failed to properly clean glucometers for 4 out of 4 residents reviewed for blood glucose monitoring (Resident #90, Resident #144, Resident #174, Resident #175). The facility failed to utilize enhanced barrier precautions for 2 out of 3 residents with a gastrostomy tube (Resident #35, Resident #90). The facility identified a census of 158 residents. Findings include: 1.) Review of Resident #90's Care Plan revealed a problem initiated on 7/23/25 for enhanced barrier precautions. It directed staff to wear personal protective equipment while providing direct care including dressing, bathing, toileting, transferring, personal hygiene, assessment/manipulation of device, and linen changes. […]

• No harm, potential for more than minimal, isolatedF759Aug 7, 2025

  Based on observation, clinical record review, and staff interview the facility failed to properly administer insulin from a Kwik pen for 2 out of 2 residents reviewed (Resident #174, Resident #175), resulting in a facility medication error rate of 8%. The facility identified a census of 158 residents.Findings include: 1.) Review of the Medication Administration Record for Resident #174 revealed an order for sliding scale insulin. On 08/06/2025 at 8:05 AM Staff A, Registered Nurse (RN) administered 2 units Lispro insulin via Kwik pen to Resident #174 and did not prime the needle prior to administration. 2.) Review of the Medication Administration Record for Resident #175 revealed a sliding scale order for Lispro Kwik pen insulin. […]

• No harm, potential for more than minimal, isolatedF656Jun 8, 2023

  Based on clinical record review, family and staff interviews, and facility policy review the facility failed to follow the care plan which directed the staff to follow the resident with a wheelchair during staff assisted ambulation which resulted in a fall with minor injuries for 1 of 3 residents' sample for fall care plans (Resident #217). The facility identified a census of 156 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #217 documented a Brief Interview for Mental Status (BIMS) score of 12 out of 15 possible points indicating mild cognitive loss. The MDS documented the resident required extensive assistance of two staff with transfers and extensive assistance of one staff for assistance walking in the corridor and locomotion on the unit. […]

• No harm, potential for more than minimal, isolatedF689Jun 8, 2023

  Based on clinical record review, family and staff interviews, resident images and facililty policy review the facility failed to provide adequate supervision when an aide left a resident that required staff assistance standing in the hallway with his walker unassisted while she went back to his room to get his wheelchair, resulting in a fall with minor injury for 1 of 3 residents reviewed (Resident #217). The facility identified a census of 156 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #217 documented a Brief Interview for Mental Status (BIMS) score of 12 out of 15 possible points indicating mild cognitive loss. […]