Stoneybrook Retirement Community

In the surveyor’s words

From the most serious findings on record at Stoneybrook Retirement Community, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 5, 2023

  The facility had a census of 40 residents. The sample included 14 residents, with two reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure a safe, hazard free environment for Resident (R) 30, who had severe cognitive impairment and poor safety awareness. She was independently mobile and had a history of wandering throughout the facility. On 01/28/23 staff observed R30 at approximately 10:23 PM. Then, at 10:30 PM, staff noted the resident was not in her room and began a search for her. The facility staff searched every room and the perimeter outside of the facility but could not locate R30. […]

• Actual harm, isolatedF689Oct 10, 2022

  The facility identified a census of 34 residents with three residents reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide a safe environment and adequate supervision for Residents (R) 1 and R2. On 09/05/22, while the facility transported R1 Certified Nurse Aide (CNA) M failed to apply safety belts to R1's wheelchair in the transportation van, causing R1 to fall backwards in the van, which resulted in a laceration (a deep cut or tear in skin or flesh) to the back of R1's scalp measuring 3 centimeters (cm) by 0.5 cm and required four staples, and a laceration to R1's outer left ankle measuring 4 cm by 3 cm, requiring 13 sutures. […]

• No harm, potential for more than minimal, widespreadF727May 14, 2026

  Based on observation, interview, and record review, the facility failed to provide Registered Nurse (RN) coverage for eight consecutive hours a day, seven days a week. Findings included:- Review of the facility's Nursing Schedule lacked consecutive eight-hour RN coverage for the following dates:02/27/2602/28/2603/1/2603/14/2603/15/2603/29/2604/11/2604/12/2605/09/2605/10/26 On 5/13/26 at 10:15 PM, Administrative Staff A stated they have a scheduler for nursing staff, and then Administrative Nurse D would look over the scheduler. […]

• No harm, potential for more than minimal, widespreadF865Apr 5, 2023

  The facility had a census of 40 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility's Quality Assessment and Assurance (QAA) program failed to make good faith efforts to identify multiple issues of concern for the 40 residents, who resided in the facility. This placed the residents at risk for decreased quality of care. Findings included: - Based on observation, record review, and interview, the facility failed to provide Resident (R) 30 and R20 care in a manner to maintain and enhance dignity and respect. Refer to F550. Based on observation, record review, and interview, the facility failed to notify R29's physician of a change of condition. […]

• No harm, potential for more than minimal, widespreadF880Apr 5, 2023

  The facility had a census of 40 residents. The sample included 14 residents. Based on observation, record review, and interview the facility failed to provide a sanitary environment to help prevent the development and transmission of communicable disease and infections when the facility failed to develop a water management plan to minimize the risk for development of Legionella (type of bacteria that can cause serious lung infections) or other waterborne pathogens (agents that cause disease or infection) from entering the facility water system. The facility staff further failed to assess and document washing machine temperatures. Staff failed to isolate Resident (R) 36 after exposure to his roommate's symptomatic COVID (highly contagious, potentially fatal respiratory infection). […]