The Carlyle at Stonebridge Park

In the surveyor’s words

From the most serious findings on record at The Carlyle at Stonebridge Park, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Aug 22, 2025

  Based on observation, interview, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive assessment of a resident for 1 of 5 residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1's catheter/catheter balloon remained in place in the bladder. On 08/04/25, the resident had a change in condition, and the NP ordered bloodwork, a UA, and a catheter change. During the catheter change, Resident #1 began to bleed from the catheter site and a few hours later, labs from the bloodwork came back critical and was sent to the hospital. […]

• Immediate jeopardy, isolatedF694Oct 19, 2023

  Based on observation, interview, and record review, the facility failed to administer parenteral fluids consistent with professional standards of practice and in accordance with physician orders for one (Resident #1) of one resident reviewed for parenteral fluids. The facility failed to obtain physician orders to manage, provide care, and change Resident #1's CVC dressing at least every 7 days and as needed if the dressing or site appeared compromised (damp, loosened or visibly soiled). The facility failed to change Resident #1's CVC dressing at least every 7 days and ensure Resident #1's central line was maintained per professional standards and facility policy. […]

• No harm, potential for more than minimal, patternF554Jan 8, 2026

  Based on observation, interview and record review the facility failed to ensure the interdisciplinary team determined if a resident was able to self-administer medications for 3 of 33 residents (Resident #41, Resident #115 and Resident #118) reviewed for resident rights.1.The facility's interdisciplinary team failed to ensure Resident #41 was clinically appropriate to self-administer Fluticasone Propionate Nasal Spray, Azelastine HCL and Major Deep Sea Premium Saline Nasal Spray that were at the resident's bedside.2.The facility failed to ensure Resident #115, with nasal spray at her bedside, was clinically appropriate to self-administer medications that were at the resident's bedside.3. […]

• No harm, potential for more than minimal, patternF684Jan 8, 2026

  Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 44 residents (Resident #45) reviewed for quality of care. The facility failed to obtain physician orders for the use of an arm sling and leg brace for Resident #45. This failure placed residents at risk of not receiving appropriate care and worsening of their conditions.Findings included: Record review of Resident #45's admission MDS assessment, dated 10/06/25, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, patternF687Jan 8, 2026

  Based on observations, interviews, and record review, the facility failed to ensure residents received proper treatment and care to maintain good foot health by providing foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition 2 of 5 residents (Resident #42 and Resident #75) reviewed for foot care. The facility failed to provide Resident #42 and Resident #75 assistance with toenail care. […]