Deficiencies (last 8 years)
Deficiencies (over 8 years)
18.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
244% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
46% occupied
Based on a December 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 2
Date: Dec 8, 2025
Visit Reason
The inspection was conducted in response to complaints regarding the use and documentation of feeding tube administration and adequacy of nursing staff at the facility.
Complaint Details
Complaint #2679872 related to feeding tube administration and documentation; Complaint #2675273 related to inadequate nursing staff.
Findings
The facility failed to ensure proper administration and documentation of supplemental tube feeding for one resident, and failed to provide adequate nursing staff as determined by their facility assessment.
Deficiencies (2)
Failure to ensure one resident received supplemental liquid nutrition via gastrostomy tube as ordered and failure to document administration in the Treatment Administration Record.
Failure to provide enough nursing staff every day to meet the needs of every resident and to have a licensed nurse in charge on each shift.
Report Facts
Census: 55
Average daily census: 54.6
Certified Nurse Aides required: 6
Certified Nurse Aides required: 4
Certified Nurse Aides required: 3
Certified Medication Technicians required: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse A | Registered Nurse | Interviewed regarding feeding tube administration and documentation |
| Director of Nursing | Director of Nursing | Interviewed regarding staff expectations for following physician orders and documentation |
| Administrator | Administrator | Interviewed regarding staff education and staffing schedule responsibility |
| Regional Director of Operations | Regional Director of Operations | Interviewed regarding auditing of resident Treatment Administration Records and staffing changes |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 2
Date: Aug 22, 2025
Visit Reason
The inspection was conducted based on complaints regarding failure to ensure proper respiratory care and failure to serve food at safe and appetizing temperatures.
Complaint Details
Complaint# 2587511 and 2587447. The complaint involved failure to ensure proper respiratory care and failure to serve food at safe temperatures.
Findings
The facility failed to ensure oxygen tubing and nebulizer masks were changed weekly for four residents and failed to provide oxygen therapy orders for one resident. Additionally, the facility failed to serve hot food at safe temperatures, with meals served below the required 120°F, risking resident safety.
Deficiencies (2)
Failed to ensure oxygen tubing and/or nebulizer mask and tubing were changed at least weekly for four residents and failed to provide orders for oxygen therapy for one resident.
Failed to ensure prepared food items were served at a safe and appetizing temperature, with hot food temperatures below 120°F upon service.
Report Facts
Facility census: 58
Food temperature: 91.5
Food temperature: 98
Required minimum food temperature: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed regarding oxygen therapy orders and responsibility for ensuring tubing changes and meal delivery monitoring | |
| Licensed Practical Nurse (LPN) A | Interviewed about responsibility for changing oxygen tubing and nebulizer masks | |
| Certified Nursing Assistant (CNA) B | Interviewed about meal service practices | |
| Administrator | Interviewed about meal delivery responsibilities and food temperature monitoring | |
| Dietary Staff Member [NAME] C | Interviewed about food plating and temperature standards |
Inspection Report
Routine
Census: 53
Deficiencies: 13
Date: Dec 4, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including employee background checks, resident notifications, care planning, safe resident transfers, medication administration, food service, staffing, infection control, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to complete required employee background checks prior to hire, failure to notify Ombudsman and residents about hospital transfers and bed hold policies, incomplete comprehensive care plans for residents, unsafe mechanical lift transfers, inaccurate bed rail assessments and lack of entrapment risk assessments, insufficient RN coverage, failure to post nurse staffing daily, medication errors including undated insulin pens and late medication administration, improper food storage and handling, incomplete Legionella water management plan, incomplete two-step TB testing for employees, failure to perform proper hand hygiene during resident care, and failure to implement Enhanced Barrier Precautions consistently.
Deficiencies (13)
Failure to check Employee Disqualification List and criminal background checks prior to hire for multiple employees.
Failure to notify Ombudsman for residents transferred to hospital and failure to provide written bed hold policy information.
Failure to develop and implement comprehensive person-centered care plans for residents.
Unsafe mechanical lift transfers with residents left suspended without two staff support and improper positioning of lift legs.
Failure to accurately assess bed rail use and complete entrapment risk assessments for residents using side rails or grab bars.
Failure to provide RN coverage for at least eight consecutive hours per day, seven days per week.
Failure to post nurse staffing information daily and maintain records for 18 months.
Medication error rate exceeded 5% due to undated insulin pens and late medication administration.
Failure to properly label and discard expired insulin medications and other food items; improper food storage and uncovered meals; ice scoop stored in ice; and lack of ice machine drain air gap.
Failure to develop and implement complete Legionella water management policies and procedures.
Failure to complete two-step purified protein derivative (PPD) testing for tuberculosis for multiple employees.
Failure to perform hand hygiene before and after glove use during perineal care for residents.
Failure to implement Enhanced Barrier Precautions including lack of staff education, signage, and PPE use for residents requiring precautions.
Report Facts
Facility census: 53
Medication error rate: 25.93
RN coverage hours: 7.55
RN coverage hours: 7.9
RN coverage hours: 7.83
RN coverage hours: 7.6
RN coverage hours: 7
RN coverage hours: 4.87
RN coverage hours: 6.83
RN coverage hours: 6.52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA I | Certified Nurse Aide | Named in background check and TB testing deficiencies |
| LPN J | Licensed Practical Nurse | Named in background check, TB testing, and medication administration deficiencies |
| Receptionist K | Receptionist | Named in background check and TB testing deficiencies |
| Social Services Director | Named in background check and Ombudsman notification deficiencies | |
| Certified Medication Technician L | Certified Medication Technician | Named in background check and medication administration deficiencies |
| Housekeeper N | Housekeeper | Named in background check and TB testing deficiencies |
| Nurse Aide B | Nurse Aide | Named in background check and TB testing deficiencies |
| Food Service Manager | Dietary Supervisor | Named in dietary qualifications and food service deficiencies |
| CMT O | Certified Medication Technician | Named in medication administration and insulin pen labeling deficiencies |
| CMT Q | Certified Medication Technician | Named in insulin pen labeling deficiencies |
| LPN G | Licensed Practical Nurse | Named in medication error and Enhanced Barrier Precautions deficiencies |
| NA A | Nurse Aide | Named in hand hygiene deficiency |
| CNA E | Certified Nursing Aide | Named in mechanical lift, hand hygiene, and Enhanced Barrier Precautions deficiencies |
| NA B | Nurse Aide | Named in mechanical lift, hand hygiene, and Enhanced Barrier Precautions deficiencies |
| NA C | Nurse Aide | Named in hand hygiene and Enhanced Barrier Precautions deficiencies |
| CNA R | Certified Nursing Aide | Named in hand hygiene and Enhanced Barrier Precautions deficiencies |
| LPN H | Licensed Practical Nurse | Named in Enhanced Barrier Precautions deficiencies |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including background checks, TB testing, medication errors, hand hygiene, and infection control |
| Business Office Manager | Business Office Manager | Interviewed regarding background check processes |
| Administrator | Administrator | Interviewed regarding multiple deficiencies including staffing, background checks, medication errors, and infection control |
| Dietary Supervisor | Dietary Supervisor | Interviewed regarding food service and dietary qualifications |
| Human Resources Manager | Human Resources Manager | Interviewed regarding dietary supervisor qualifications |
| Plant Supervisor | Plant Supervisor | Interviewed regarding Legionella water management and ice machine air gap |
| Housekeeping Supervisor | Housekeeping Supervisor | Interviewed regarding water system flushing and Legionella control |
| Registered Dietician | Registered Dietician | Interviewed regarding food service and dietary deficiencies |
| Shower Aide T | Shower Aide | Interviewed regarding ice scoop storage |
Inspection Report
Plan of Correction
Census: 53
Deficiencies: 14
Date: Dec 4, 2024
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Stonebridge Adams Street facility following a survey completed on 12/04/2024. It addresses regulatory compliance issues identified during the inspection.
Findings
The facility was found non-compliant with multiple regulatory requirements including failure to conduct required background checks for employees, failure to notify the Ombudsman of resident transfers, failure to implement bed hold policies, incomplete comprehensive care plans, unsafe resident transfers, inadequate nurse staffing, medication errors above acceptable rates, improper storage and labeling of medications, food safety violations, and infection control deficiencies.
Deficiencies (14)
F607: Facility failed to develop and implement abuse and neglect policies including required background checks for employees prior to hire. Several employee personnel records lacked documentation of completed background checks.
F623: Facility failed to notify the Ombudsman of resident transfers to hospital for four residents. The facility also failed to provide timely and adequate transfer/discharge notices.
F625: Facility failed to provide written information regarding bed hold policy to residents or their representatives at time of transfer for four residents.
F656: Facility failed to develop and implement comprehensive, person-centered care plans for three residents. Care plans lacked measurable objectives and timeframes.
F689: Facility failed to ensure resident environment was free of accident hazards and failed to provide adequate supervision and assistance devices to prevent accidents for two residents.
F700: Facility failed to assess residents for entrapment risk from bed rails and failed to maintain safe bed rail use policies and assessments for multiple residents.
F727: Facility failed to provide services of a registered nurse for at least eight consecutive hours daily, seven days a week, as required.
F732: Facility failed to post nurse staffing information daily and failed to maintain staffing records for 18 months.
F759: Facility failed to maintain medication error rates below 5%, with a 25.93% error rate observed. Staff failed to follow medication administration policies.
F761: Facility failed to properly label and store drugs and biologicals, including expired insulin pens and improper medication storage.
F800: Facility failed to provide each resident with a nourishing, palatable, well-balanced diet meeting daily nutritional needs and failed to follow standardized recipes.
F801: Facility failed to employ a qualified dietary manager and failed to ensure dietary staff met appropriate qualifications.
F812: Facility failed to maintain sanitary food procurement, storage, preparation, and serving practices, including improper labeling and storage of food items.
F880: Facility failed to establish and maintain an infection prevention and control program including water management and tuberculosis screening for employees.
Report Facts
Facility census: 53
Medication error rate: 25.93
Medication opportunities observed: 27
Medication errors observed: 7
Plan of Correction completion date: Jan 10, 2025
Plan of Correction completion date: Dec 10, 2024
Plan of Correction completion date: Dec 5, 2024
Plan of Correction completion date: Dec 11, 2024
Inspection Report
Life Safety
Census: 53
Capacity: 120
Deficiencies: 9
Date: Dec 4, 2024
Visit Reason
The inspection was a Life Safety Code survey conducted to assess compliance with fire safety and emergency preparedness regulations at Stonebridge Adams Street facility.
Findings
The facility was found deficient in emergency preparedness related to emergency lighting and exit sign battery backup testing. Multiple fire safety deficiencies were identified including failure to maintain kitchen hood suppression systems, fire alarm system modifications without proper notification, incomplete fire alarm testing and maintenance, sprinkler system obstructions, smoke barrier maintenance issues, improper use of portable space heaters, and electrical equipment violations.
Deficiencies (9)
E015 Emergency preparedness policies failed to ensure emergency lighting and exit signs had battery backup and were tested monthly and annually. Exit signs were found not illuminated or tested during inspection.
K324 Kitchen hood suppression system was not cleaned semi-annually as required, with inaccessible areas preventing full cleaning. Facility policies lacked inspection and maintenance procedures for the system.
K341 Fire alarm system modifications were made without notifying the authority having jurisdiction. Records lacked documentation of system testing after changes and nuisance alarm records.
K345 Fire alarm system testing and maintenance were incomplete. Records did not show sensitivity testing of smoke detectors or documentation of nuisance alarms. Annual inspection was incomplete.
K353 Sprinkler system was obstructed by boxes, gaps around sprinkler heads, and missing signage. Temporary waiver requested for hydraulic nameplate. Inspection schedules and maintenance documentation were incomplete.
K372 Smoke barrier walls had unsealed penetrations and drywall patches, allowing potential smoke passage. Inspection and maintenance of barriers were incomplete.
K781 Portable space heaters were used in resident areas despite policy prohibiting them. Observations showed space heaters plugged into extension cords and splitters.
K920 Electrical equipment violations included use of extension cords and power strips in patient care areas, improper surge protector use, and unsecured electrical devices near residents.
K926 Facility failed to provide education on medical gas safety and oxygen handling to all staff. Training completion was below 65% at time of inspection.
Report Facts
Facility census: 53
Total capacity: 120
Staff training completion: 34
Staff total: 52
Deficiency counts: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Plant Supervisor | Interviewed regarding emergency lighting, fire alarm system, kitchen hood cleaning, sprinkler system, and electrical safety findings | |
| Administrator | Interviewed regarding emergency lighting, fire alarm system, kitchen hood cleaning, sprinkler system, electrical safety, and staff training findings | |
| Maintenance Director | Responsible for monitoring corrective actions related to fire safety and electrical deficiencies |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 2
Date: Oct 17, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure of facility staff to notify the responsible party and physician after an unwitnessed fall of a resident, and failure to complete neurological checks for residents who had unwitnessed falls.
Complaint Details
The complaint investigation found substantiated failures in notification and neurological monitoring after unwitnessed falls. Interviews with Licensed Practical Nurses, the Director of Nursing, the administrator, and a resident's family member confirmed the failures.
Findings
The facility failed to notify the physician and family of a resident's unwitnessed fall and failed to complete neurological checks for three residents who had unwitnessed falls, despite policies requiring notification and post-fall monitoring. Interviews with staff and family confirmed these failures.
Deficiencies (2)
Facility staff failed to contact one resident's responsible party and physician after an unwitnessed fall.
Facility staff failed to complete neurological checks for three residents who had unwitnessed falls.
Report Facts
Facility census: 54
Falls for Resident #3: 2
Falls for Resident #2: 3
Falls for Resident #1: 0
Neurological checks duration: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse | Interviewed regarding fall notification and neurological checks; did not notify physician or family after resident's fall |
| Licensed Practical Nurse D | Licensed Practical Nurse | Interviewed regarding fall notification and neurological checks; confirmed policy requirements |
| Licensed Practical Nurse F | Licensed Practical Nurse | Interviewed regarding neurological checks after falls |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for notification and neurological checks after falls |
| Administrator | Administrator | Interviewed regarding staff expectations for notification and neurological checks after falls |
Inspection Report
Plan of Correction
Census: 54
Deficiencies: 5
Date: Oct 17, 2024
Visit Reason
The inspection was conducted to investigate deficiencies related to notification of changes in resident condition and comprehensive care plans following unwitnessed falls at Stonebridge Adams Street facility.
Findings
The facility failed to promptly notify physicians and responsible parties of resident changes and unwitnessed falls. Staff also failed to complete required neurological checks for residents after falls, and documentation was incomplete or missing.
Deficiencies (5)
F580 Notification of Changes: The facility failed to notify the resident's physician and responsible party promptly after an unwitnessed fall and significant changes in condition.
F658 Services Provided Meet Professional Standards: The facility failed to complete neurological checks for three residents who had unwitnessed falls as required by policy.
A4075 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met.
A4087 Doctor Notification-Change in Condition: Facility staff failed to notify the resident's physician in accordance with emergency treatment policies after accidents or significant changes.
A4088 Notify Responsible Party-Change in Condition: Facility staff failed to immediately notify the responsible party of accidents or significant changes in condition.
Report Facts
Facility census: 54
Falls for Resident #2: 3
Falls for Resident #3: 2
Falls for Resident #1: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) A | Licensed Practical Nurse | Interviewed regarding notification of falls and physician contact |
| Licensed Practical Nurse (LPN) D | Licensed Practical Nurse | Interviewed regarding notification of unwitnessed falls and documentation |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding nurse notification expectations and neurological checks |
| Administrator | Administrator | Interviewed regarding staff notification responsibilities |
Inspection Report
Annual Inspection
Census: 55
Deficiencies: 1
Date: Jul 1, 2024
Visit Reason
The inspection was conducted to evaluate the nursing facility's compliance with professional standards of quality, specifically focusing on post-fall neurological checks and documentation for residents who experienced unwitnessed falls.
Findings
The facility failed to complete the required 72-hour neurological checks and fall follow-up documentation for three sampled residents who had unwitnessed falls. Interviews with nursing staff and administration confirmed the expectation for these checks and documentation, but they were not completed.
Deficiencies (1)
Failure to complete neurological checks and fall follow-up documentation for three residents who had unwitnessed falls.
Report Facts
Facility census: 55
Falls documented: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse B | Licensed Practical Nurse (LPN) | Interviewed regarding responsibility for neurological checks and fall follow-up documentation |
| Licensed Practical Nurse C | Licensed Practical Nurse (LPN) | Interviewed regarding responsibility for neurological checks and fall follow-up documentation |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding responsibility for ensuring neurological checks are completed |
| Administrator | Administrator | Interviewed regarding expectations for neurological checks and documentation |
Inspection Report
Plan of Correction
Census: 55
Deficiencies: 2
Date: Jul 1, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards related to comprehensive care plans and nursing care, specifically focusing on neurological checks and fall follow-up documentation after unwitnessed falls.
Findings
The facility failed to complete neurological checks and fall follow-up documentation for three residents who had unwitnessed falls. Staff interviews confirmed that nurses and the Director of Nursing are responsible for completing these checks, but documentation was incomplete.
Deficiencies (2)
F658 Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i). Facility staff failed to complete neurological checks and fall follow-up documentation for three residents with unwitnessed falls. Documentation for 72-hour neurological checks was missing for falls on 5/5/24, 5/11/24, and 6/14/24.
A4075 19 CSR 30-85.042(66) Nursing Care per Resident Condition. Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation is not met as evidenced by the deficiency cited in F658.
Report Facts
Facility census: 55
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Keri White | Administrator | Signed the report and plan of correction |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 1
Date: Feb 15, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a failure to provide proper transfer assistance to a resident, resulting in injury.
Complaint Details
The complaint investigation found that staff did not utilize two-person assistance as required for Resident #1, leading to a leg injury. The resident was assessed as requiring two-person transfers due to severe cognitive impairment and bilateral lower extremity impairments. Staff interviews indicated confusion or lack of awareness about the resident's transfer needs.
Findings
Facility staff failed to follow the care plan requiring two-person assistance for transfers, leading to a resident sustaining a comminuted tibia-fibula fracture. Interviews revealed inconsistent knowledge and adherence to transfer protocols among staff.
Deficiencies (1)
Failure to provide proper transfer assistance as required by the resident's care plan, resulting in injury.
Report Facts
Facility census: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse | Documented resident's leg pain and injury |
| Certified Nursing Assistant B | Certified Nursing Assistant | Interviewed regarding resident transfer knowledge |
| Certified Nursing Assistant C | Certified Nursing Assistant | Interviewed about transferring resident alone |
| Certified Nursing Assistant D | Certified Nursing Assistant | Interviewed about resident transfer requirements |
| Certified Nursing Assistant E | Certified Nursing Assistant | Interviewed about care plan alerts and transfer practices |
| Physical Therapist | Physical Therapist | Interviewed about resident transfer assessment |
| Administrator | Administrator | Interviewed about facility policy and staff adherence |
| Resident's Physician | Physician | Interviewed about resident's frailty and transfer needs |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 2
Date: Feb 15, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident injury related to inadequate supervision and assistance during transfers.
Complaint Details
The visit was complaint-related due to a resident injury caused by failure to follow the care plan for transfers. The complaint was substantiated as staff did not use two-person assistance, leading to a fractured tibia-fibula shaft.
Findings
The facility failed to provide proper transfer assistance for a resident, resulting in an injury. Staff did not utilize two-person assistance as required by the resident's care plan, leading to a fractured leg.
Deficiencies (2)
F689 Free of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2) The facility failed to provide adequate supervision and assistance devices to prevent accidents, resulting in a resident injury during transfer when two-person assistance was not used as required.
A4074 19 CSR 30-85.042(65) Protective Oversight, Voluntary Leave The facility did not have a procedure to inquire about the resident's whereabouts and estimated length of absence during voluntary leave, violating protective oversight requirements.
Report Facts
Facility census: 56
Inspection Report
Routine
Census: 53
Deficiencies: 7
Date: Nov 17, 2023
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident dignity, care planning, medication administration, respiratory care, food safety, and infection prevention.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity and privacy, incomplete and outdated care plans, failure to maintain professional standards in documentation and medication storage, inadequate respiratory equipment cleaning and storage, improper food storage and handling practices, failure to perform proper hand hygiene, and lack of a designated qualified infection preventionist.
Deficiencies (7)
Facility staff failed to ensure residents were treated with dignity and privacy, including failure to announce themselves before entering rooms and improper display of care signs visible from hallways.
Failed to update resident care plans to reflect current needs such as oxygen use and code status changes.
Failed to maintain professional standards of documentation including lack of physician orders for assistive devices, incomplete bed rail assessments, missed weekly skin assessments, and failure to consult physician on dietary recommendations.
Failed to clean and store respiratory equipment properly to prevent infection for nine residents, including dirty filters, undated tubing, and nebulizer masks not stored in bags.
Failed to store and label medications and biologicals safely and securely, including unlocked medication and treatment carts, expired and unlabeled medications, and medications left unattended.
Failed to procure, store, prepare, and serve food in accordance with professional standards, including undated and uncovered food items, failure to perform hand hygiene, use of wet stacked dishes, and failure to wear hair restraints in the kitchen.
Failed to designate a qualified infection preventionist responsible for the infection prevention and control program.
Report Facts
Facility census: 53
Deficiency count: 7
Oxygen tubing change frequency: 1
Medication expiration date: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT C | Certified Medication Technician | Interviewed regarding dignity, privacy, and oxygen tubing practices |
| LPN B | Licensed Practical Nurse | Interviewed regarding skin assessments and dietary recommendations |
| DON | Director of Nursing | Interviewed regarding care plan updates, medication storage, and infection control |
| Administrator | Interviewed regarding facility policies on dignity, medication storage, and infection control | |
| DM | Dietary Manager | Interviewed regarding food storage, hand hygiene, and hair restraint policies |
| DA M | Dietary Aide | Observed and interviewed regarding hand hygiene and food service |
| DA N | Dietary Aide | Observed handwashing practices |
| Resident #34 | Interviewed regarding dignity and privacy concerns | |
| Resident #15 | Observed during oxygen and nebulizer use |
Inspection Report
Annual Inspection
Census: 53
Deficiencies: 7
Date: Nov 17, 2023
Visit Reason
Annual inspection survey conducted on 11/17/2023 to assess compliance with federal and state regulations for Stonebridge Adams Street nursing facility.
Findings
The facility was found noncompliant with multiple federal regulations including resident rights, comprehensive care planning, infection control, medication management, food safety, and staff training. Deficiencies ranged from failure to maintain resident dignity and privacy to inadequate documentation and unsafe medication storage.
Deficiencies (7)
F550 Resident Rights: Facility staff failed to ensure residents were treated with dignity and privacy, including failure to announce before entering rooms and maintain door privacy during medication administration.
F656 Comprehensive Care Plan: Facility failed to update care plans for residents with oxygen use and advanced directives, and did not ensure care plans were trauma-informed and culturally competent.
F658 Services Provided Meet Professional Standards: Facility failed to maintain professional standards in documentation, including lack of physician orders for assistive devices and incomplete skin assessments.
F695 Respiratory/Tracheostomy Care: Facility failed to clean and store respiratory equipment properly, increasing infection risk for nine residents.
F761 Label/Store Drugs and Biologicals: Facility failed to store and label medications and biologicals safely and effectively, including expired medications and unlocked medication carts.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: Facility failed to store food safely, including uncovered and undated food items and poor hygiene practices among food service staff.
F882 Infection Preventionist Qualifications/Role: Facility failed to designate qualified infection preventionist staff and maintain an effective infection prevention and control program.
Report Facts
Facility census: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT C | Certified Medication Technician | Named in medication administration and care plan findings |
| CNA H | Certified Nurse Assistant | Named in resident privacy and care findings |
| Director of Nursing | Director of Nursing (DON) | Named in multiple findings related to staff training, care planning, and infection control |
| Administrator | Facility Administrator | Named in findings related to resident privacy and staff compliance |
| LPN B | Licensed Practical Nurse | Named in skin assessment and dietary recommendation findings |
| Dietary Manager | Dietary Manager (DM) | Named in food safety and storage findings |
| Cook K | Cook | Named in food handling and hygiene findings |
| Cook L | Cook | Named in food handling and hygiene findings |
| DA M | Dietary Aide | Named in food handling and hygiene findings |
| DA N | Dietary Aide | Named in food handling and hygiene findings |
| QAPI committee | Responsible for reviewing corrective actions monthly |
Inspection Report
Life Safety
Census: 53
Capacity: 120
Deficiencies: 15
Date: Nov 17, 2023
Visit Reason
The inspection was a Life Safety Code survey conducted to assess compliance with emergency preparedness, fire alarm system maintenance, sprinkler system maintenance, electrical system safety, and fire drill requirements.
Findings
The facility failed to maintain adequate emergency preparedness policies and procedures, including subsistence needs and alternate energy sources. Deficiencies were found in fire alarm system security, sprinkler system maintenance and testing, electrical panel security, fire drill documentation, and staff education on safety guidelines.
Deficiencies (15)
E015: The facility staff failed to ensure emergency preparedness policies and procedures addressed subsistence needs and alternate energy sources to maintain facility temperature, emergency lighting, fire detection, and extinguishment systems.
E041: The facility staff failed to implement emergency power system inspection, testing, and maintenance requirements and did not provide complete policies and procedures for emergency generator operation during power outages.
K345: The facility staff failed to maintain the fire alarm system in accordance with NFPA 72 by not securing the control panel against unauthorized access and use.
K353: The facility staff failed to inspect, test, and maintain the wet pipe sprinkler system, including documentation of system acceptance, maintenance, and testing records.
K511: The facility staff failed to secure electrical panels against unauthorized access and maintain clear access and working space for safe operation and maintenance.
K712: The facility staff failed to conduct fire drills quarterly on each shift as required and maintain documentation of fire drills for the previous year.
K918: The facility failed to have a generator meeting emergency backup requirements and failed to install a functional remote alarm annunciator connected to the generator.
K926: The facility staff failed to provide education on safety guidelines and usage requirements for medical gases and cylinders to all staff involved with their application, handling, and maintenance.
A1002: The facility failed to submit schematic and preliminary plans for the installation of a 30 kilowatt natural gas generator to the Department of Health and Senior Services for approval prior to installation.
A2019: The facility failed to maintain complete fire alarm systems and test and maintain the system in accordance with NFPA 72.
A2034: The facility failed to maintain the sprinkler system in accordance with NFPA 25 requirements.
A2058: The facility failed to conduct fire drills and emergency preparedness as required by regulations, including documentation and frequency.
A2061: The facility failed to conduct required fire drills including evacuation procedures at least annually.
A3030: The facility failed to maintain electrical wiring and equipment in accordance with NFPA 70 and NFPA 99 standards.
A4022: The facility failed to provide in-service orientation and continuing education for staff regarding infection prevention and control, confidentiality, and resident dignity.
Report Facts
Facility census: 53
Total capacity: 120
Date of survey: Nov 17, 2023
Inspection Report
Plan of Correction
Census: 54
Deficiencies: 1
Date: Sep 28, 2023
Visit Reason
The inspection was conducted to assess compliance with emergency preparedness requirements for residents on continuous respiratory devices during a power outage.
Findings
The facility failed to develop and implement an emergency plan for residents on continuous respiratory devices during a power outage, resulting in inadequate precautions and lack of specific interventions for oxygen and BiPAP use. One resident on a BiPAP machine experienced respiratory distress and subsequent death during the power outage due to these deficiencies.
Deficiencies (1)
E 015: The facility failed to develop and implement an emergency preparedness plan addressing subsistence needs for residents on continuous respiratory devices during a power outage. Staff did not take adequate precautions to maintain oxygen and BiPAP use during loss of power, contributing to a resident's respiratory distress and death.
Report Facts
Facility census: 54
Plan of Correction compliance date: Compliance to be achieved by 10-17-23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding resident's care and emergency plan during power outage |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN A) | Interviewed about storm preparation and resident care during power outage |
| Certified Nurse's Aide | Certified Nurse's Aide (CNA A) | Assisted resident during power outage and oxygen administration |
| Administrator | Administrator | Interviewed about emergency plan and communication with resident's family |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 1
Date: Aug 9, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident where a Certified Nursing Assistant (CNA A) physically abused a resident by not releasing the resident's wrists during a transfer and forcefully pushing the resident in the stomach, resulting in a bruise.
Complaint Details
The complaint investigation was substantiated. CNA A physically abused Resident #1 on 7/27/23 by holding the resident's wrists and pushing the resident in the stomach. The incident was witnessed by LPN B and other staff. CNA A was suspended, investigated, and terminated. The local police and Department of Health and Senior Services were notified. The resident had a purple bruise on the right arm documented during follow-up.
Findings
The investigation found that CNA A physically abused Resident #1 by holding the resident's wrists during a transfer and then forcefully pushing the resident in the stomach with a closed fist, causing a bruise. The facility took immediate action by suspending and terminating CNA A, notifying appropriate parties, and providing staff education on abuse and neglect policies.
Deficiencies (1)
Facility staff failed to ensure one resident remained free from physical abuse when a staff member did not release the resident's wrists during a transfer and forcefully pushed the resident in the stomach, resulting in a bruise.
Report Facts
Facility census: 54
Bruise measurement: 2.5
Bruise measurement: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Named in physical abuse finding for holding resident's wrists and pushing resident in the stomach |
| LPN B | Licensed Practical Nurse | Witnessed the abuse incident and notified the administrator |
| CNA C | Certified Nursing Assistant | Witness and reporter of the incident, assisted in lifting the resident |
| CNA D | Certified Nursing Assistant | Witness and reporter of the incident, assisted in lifting the resident |
| Administrator | Facility Administrator | Notified of the incident, removed CNA A from the building, and terminated CNA A |
| Assistant Director of Nursing | ADON | Completed investigation and suspended CNA A pending investigation |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 1
Date: Aug 9, 2023
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted, along with an investigation of a complaint regarding physical abuse of a resident by a Certified Nursing Assistant (CNA).
Complaint Details
The complaint investigation substantiated that a Certified Nursing Assistant physically abused a resident on 7/27/23. The CNA was suspended, investigated, and terminated. Staff were re-educated on abuse and neglect policies.
Findings
The facility was found in compliance with COVID-19 related regulations. However, a deficiency was found related to abuse and neglect where a CNA physically abused a resident by forcefully pushing and hitting the resident during a transfer. The CNA was suspended and terminated following investigation.
Deficiencies (1)
F 600: The facility failed to ensure one resident remained free from physical abuse when a staff member forcefully pushed the resident in the stomach with closed fists during a transfer.
Report Facts
Facility census: 54
Bruise measurement: 2.5
Bruise measurement: 4
Date of abuse incident: Jul 27, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bethany Eads | LNHA | Signed as Laboratory Director or Provider/Supplier Representative on report |
| CNA A | Certified Nursing Assistant who physically abused the resident and was terminated | |
| CNA C | Certified Nursing Assistant who documented events during the abuse incident | |
| CNA D | Certified Nursing Assistant involved in the incident and documented observations | |
| LPN B | Licensed Practical Nurse | Witnessed the incident and reported it to the administrator |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 9, 2023
Visit Reason
The document is an annual inspection report for Stonebridge Adams Street nursing home, summarizing the findings of the survey completed on 08/09/2023.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 21, 2023
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Deficiencies: 0
Date: Jul 21, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Stonebridge Adams Street nursing home, summarizing the findings from the survey completed on 07/21/2023.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 2
Date: Sep 15, 2022
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident who fell out of a wheelchair during transport, resulting in injury.
Complaint Details
The complaint investigation was substantiated by findings that a resident was not properly secured in a wheelchair during transport, leading to a fall and injury. The facility also failed to provide required protective oversight for residents on voluntary leave.
Findings
The facility failed to properly secure a resident's wheelchair during transport, leading to the resident falling and sustaining injuries. The facility also failed to provide adequate protective oversight and supervision for residents on voluntary leave.
Deficiencies (2)
F 689 Free of Accident Hazards/Supervision/Devices: The facility failed to properly secure a resident's wheelchair during transport, resulting in the resident falling out of the wheelchair and sustaining injuries.
A4074 Protective Oversight, Voluntary Leave: The facility did not ensure twenty-four-hour protective oversight and supervision for residents on voluntary leave, violating the regulation.
Report Facts
Facility census: 61
Inspection Report
Life Safety
Census: 53
Capacity: 120
Deficiencies: 10
Date: Jun 3, 2022
Visit Reason
The inspection was conducted as a Life Safety Code survey to evaluate compliance with emergency preparedness, fire safety, and related regulatory requirements at Stonebridge Adams Street facility.
Findings
The facility failed to maintain and update the emergency preparedness plan annually and did not provide required emergency preparedness training to staff. Deficiencies were also found in emergency lighting testing, fire drills, fire door inspections, generator maintenance, oxygen storage, and documentation of safety procedures.
Deficiencies (10)
E004: The facility failed to review and update the emergency preparedness plan annually, including updating for current staff and emergency generator changes.
E037: The facility failed to provide annual emergency preparedness training to all staff and maintain documentation of such training.
K291: The facility failed to maintain complete and verifiable documentation of monthly and annual emergency lighting tests and failed to ensure emergency lighting for means of egress.
K712: The facility failed to conduct fire drills at various times and shifts quarterly and maintain complete documentation of fire drills.
K761: The facility failed to provide complete and verifiable documentation of annual inspection and monthly testing of fire-rated door assemblies and non-rated corridor doors.
K918: The facility failed to provide complete and verifiable documentation of weekly visual generator inspections and monthly 30-minute load tests of the generator.
K923: The facility failed to maintain oxygen storage room free of combustible materials within five feet of oxygen cylinders, creating a fire hazard.
A2050: The facility failed to maintain emergency lighting of sufficient intensity for safety of residents and others using exits, stairways, and corridors.
A2063: The facility failed to keep records of all fire drills including simulated resident evacuation with time, date, personnel, and narrative of problems.
A3030: The facility failed to maintain electrical wiring and equipment in accordance with NFPA 70 standards.
Report Facts
Facility census: 53
Total capacity: 120
Number of pages: 38
Inspection Report
Routine
Census: 53
Deficiencies: 9
Date: Jun 3, 2022
Visit Reason
Routine inspection of Stonebridge Adams Street nursing home to assess compliance with regulatory requirements including resident fund security, resident rights notification, care planning, medication management, catheter care, bed rail use, and food storage.
Findings
The facility was found deficient in multiple areas including failure to maintain adequate surety bond for resident funds, failure to inform residents of their rights, incomplete and outdated care plans for residents, inadequate documentation and physician orders for catheter care and oxygen use, failure to properly assess and monitor bed rail use, failure to follow professional standards for medication management including psychotropic drugs, and improper food storage practices.
Deficiencies (9)
Facility staff failed to maintain a surety bond sufficient to ensure protection of resident funds for all sampled residents.
Facility staff failed to inform residents of their rights during their stay in the facility.
Facility staff failed to develop and implement comprehensive person-centered care plans addressing residents' medical and nursing needs including code status, falls, and oxygen use.
Facility staff failed to revise care plans timely for changes in residents' conditions and failed to follow care plans for fall prevention.
Facility staff failed to provide care consistent with professional standards including failure to document assessments and notify physicians after resident falls, failure to obtain physician orders for code status and oxygen, and failure to clean oxygen concentrator filters.
Facility staff failed to obtain physician orders for indwelling urinary catheters, catheter care, catheter/balloon size, and indication for use for residents, including one with a urinary tract infection.
Facility staff failed to complete ongoing assessments and obtain consents for bed rail use to assure they met residents' needs.
Facility staff failed to ensure appropriate indications and diagnoses for psychotropic medication use, failed to attempt gradual dose reductions, and failed to communicate pharmacy recommendations to physicians.
Facility staff failed to store food properly to prevent cross-contamination and out-dated use, including unlabeled, undated, unsealed, and spoiled food items in refrigerators and freezers.
Report Facts
Facility census: 53
Residents sampled for surety bond: 18
Average monthly balance: 29324
Required bond amount: 43986
Current bond amount: 30000
Psychotropic medication days: 7
Food storage violation count: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Named in surety bond deficiency interviews | |
| Administrator | Named in surety bond, resident rights, care plan, oxygen, catheter care, bed rail, and food storage deficiencies | |
| Certified Nurse Aide F | CNA | Interviewed regarding resident rights, care plans, oxygen, catheter care, bed rail assessments |
| Certified Nurse Aide G | CNA | Interviewed regarding resident rights, care plans, catheter care, bed rail assessments |
| Director of Nursing | DON | Interviewed regarding care plans, oxygen, catheter care, bed rail assessments, medication management |
| Assistant Director of Nursing | ADON | Interviewed regarding resident rights, care plans, catheter care, oxygen |
| Social Services Director | SSD | Interviewed regarding resident rights, care plans, catheter care, code status |
| MDS Coordinator | Interviewed regarding resident rights, care plans, catheter care, medication management | |
| Registered Nurse D | RN | Interviewed regarding care plans, falls, catheter care, bed rail use |
| Licensed Practical Nurse E | LPN | Interviewed regarding oxygen filter cleaning |
| Dietary Manager | DM | Interviewed regarding food storage and labeling |
| Regional Nurse Consultant | Interviewed regarding medication management | |
| Physician A | Physician | Interviewed regarding catheter care and medication management |
Inspection Report
Plan of Correction
Census: 53
Deficiencies: 9
Date: Jun 3, 2022
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Stonebridge Adams Street nursing facility following a survey completed on 06/03/2022. It addresses multiple regulatory deficiencies identified during the inspection.
Findings
The facility was found non-compliant with several federal regulations including financial security of resident funds, resident rights notification, comprehensive care planning, medication management, urinary catheter care, bed rails safety, food safety, and psychotropic drug use. Deficiencies were documented with specific resident cases and policy reviews.
Deficiencies (9)
F570 Surety Bond-Security of Personal Funds: The facility failed to maintain a surety bond sufficient to protect resident funds for 18 sampled residents. The facility census was 53.
F572 Notice of Rights and Rules: Staff failed to inform residents of their rights during their stay. The facility census was 53.
F656 Develop/Implement Comprehensive Care Plan: Facility staff failed to develop comprehensive person-centered care plans for residents, including measurable objectives and timely updates. The facility census was 53.
F657 Care Plan Timing and Revision: Facility staff failed to revise care plans timely for residents with changes in condition or medication. The facility census was 53.
F658 Services Provided Meet Professional Standards: Facility staff failed to provide care consistent with professional standards, including timely physician contact after resident falls. The facility census was 53.
F690 Bowel/Bladder Incontinence, Catheter, UTI: Facility failed to ensure appropriate catheter care, obtain physician orders, and prevent urinary tract infections for residents with indwelling catheters. The facility census was 53.
F700 Bedrails: Facility failed to complete ongoing assessments for bed rail use and ensure resident safety. The facility census was 53.
F758 Free from Unnecessary Psychotropic Medications/PRN Use: Facility failed to ensure psychotropic drugs were used only when necessary and failed to document gradual dose reductions and rationale for PRN orders.
F812 Food Procurement, Store/Prepare/Serve-Sanitary: Facility staff failed to store food properly to prevent cross-contamination and out-of-date use. The facility census was 53.
Report Facts
Facility census: 53
Sampled residents for surety bond: 18
Inspection Report
Plan of Correction
Census: 53
Deficiencies: 2
Date: Apr 8, 2022
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, specifically regarding wound care and documentation practices at Stonebridge Adams Street facility.
Findings
The facility failed to meet professional standards by not documenting physician-ordered treatments for two sampled residents. Staff did not consistently document application of skin treatments as ordered, despite interventions being provided.
Deficiencies (2)
F658 Comprehensive Care Plans: Facility staff failed to document application of physician-ordered wound care treatments for two residents as required by the comprehensive care plan.
A4075 Nursing Care per Resident Condition: Each resident did not receive personal attention and nursing care consistent with current acceptable nursing practice, as evidenced by failure to meet F658 requirements.
Report Facts
Facility census: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding wound care documentation and plan of correction | |
| Director of Nursing (DON) | Interviewed regarding wound care documentation and staff education | |
| Licensed Practical Nurse (LPN) A | Interviewed about wound care orders and documentation practices |
Inspection Report
Plan of Correction
Census: 53
Deficiencies: 2
Date: Mar 21, 2022
Visit Reason
The inspection was conducted to assess compliance with infection prevention and control requirements and COVID-19 vaccination policies for facility staff.
Findings
The facility failed to use appropriate infection control procedures as staff did not wear face masks properly. Additionally, three staff members were not fully vaccinated against COVID-19, failing to meet vaccination requirements.
Deficiencies (2)
F880 Infection Prevention & Control: The facility failed to use appropriate infection control procedures to prevent the spread of infectious contaminants when staff failed to wear face masks properly.
F888 COVID-19 Vaccination of Facility Staff: The facility failed to ensure three staff members were fully vaccinated against COVID-19 or had approved exemptions or delays as required.
Report Facts
Facility census: 53
Staff vaccination rate: 97
Number of staff not fully vaccinated: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Assistant D | Staff member not fully vaccinated and late for second vaccine dose | |
| Certified Nurse Assistant E | Staff member not fully vaccinated and late for second vaccine dose | |
| Certified Med Tech F | Staff member not fully vaccinated and late for second vaccine dose | |
| Administrator | Administrator and Director of Nursing | Interviewed regarding mask use and staff vaccination compliance |
Inspection Report
Plan of Correction
Census: 52
Deficiencies: 3
Date: Aug 26, 2021
Visit Reason
The document is a Plan of Correction submitted by Stonebridge Adams Street following a survey conducted on 08/26/2021. It addresses deficiencies found during the inspection related to professional standards of care and food safety.
Findings
The facility failed to meet professional standards of care related to comprehensive care plans, including failure to obtain weights and blood pressures as ordered by physicians. Additionally, the facility failed to meet nutritional needs and food safety requirements, including serving pureed diets correctly and maintaining proper food storage and temperatures.
Deficiencies (3)
F658 Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i). The facility failed to maintain professional standards of care by not obtaining weights and blood pressures for sampled residents as ordered by physicians. Documentation of resident weights was incomplete for several periods.
F803 Menus Meet Resident Needs/Prep in Adv/Followed CFR(s): 483.60(c)(1)-(7). The facility failed to serve foods in accordance with nutritionally calculated menus for residents on pureed diets. Dietary staff served incorrect portion sizes and substituted foods without proper authorization.
F812 Food Procurement, Store/Prepare/Serve-Sanitary CFR(s): 483.60(i)(1)(2). The facility failed to store food to prevent cross-contamination and maintain proper temperatures. Food items were found stored improperly, including opened and undated items in reach-in freezers and improper labeling.
Report Facts
Facility census: 52
Inspection Report
Plan of Correction
Census: 48
Deficiencies: 7
Date: Jun 24, 2021
Visit Reason
The inspection was conducted to assess compliance with food safety and sanitation regulations at Stonebridge Adams Street facility, including review of food procurement, storage, pest control, and kitchen cleanliness.
Findings
The facility failed to maintain kitchen equipment and floors in a clean and sanitary manner, had pest infestations including live and dead cockroaches, and improper food storage with many items undated or opened. The kitchen lacked visible cleaning schedules and had equipment and food debris issues contributing to contamination risks.
Deficiencies (7)
F812 Food safety requirements were not met as facility staff failed to maintain kitchen equipment and floors clean and sanitary, ensure kitchen windows had screens, air dry dishes before storage, cover food waste receptacles, and store food to prevent contamination and out-dated use.
A6012 Floors and floor coverings in food preparation and storage areas were not maintained in good repair and clean.
A6031 Waste containers in food preparation and utensil-washing areas were not kept covered when not in use.
A6039 Effective measures to minimize presence of rodents, flies, cockroaches, and other insects were not utilized, allowing pest harborage.
A6040 Outside openings were not effectively protected against rodents with proper screening and self-closing doors.
A7015 Food was not protected from contamination during storage, display, and transport, risking resident safety.
A7086 Equipment and utensils were not air dried and stored in a self-draining position after sanitization.
Report Facts
Facility census: 48
Red food service trays: 21
Inspection Report
Routine
Deficiencies: 0
Date: Nov 10, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Plan of Correction
Census: 53
Deficiencies: 2
Date: Oct 14, 2020
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or mistreatment involving a Certified Nursing Assistant (CNA) and a resident.
Complaint Details
The visit was complaint-related due to allegations of abuse by a Certified Nursing Assistant (CNA) toward Resident #1. The complaint was substantiated as the facility failed to suspend the accused employee immediately and did not follow proper investigation procedures.
Findings
The facility failed to immediately suspend the accused CNA pending investigation after a resident alleged inappropriate touching. The Director of Nursing (DON) acknowledged a delay in suspension and the investigation was ongoing at the time of the survey.
Deficiencies (2)
F610: The facility failed to follow its Abuse/Neglect/Exploitation Policy by not immediately suspending the accused employee pending investigation after a resident alleged abuse. The investigation was not completed timely and the employee continued to work during the investigation.
A8023: The facility did not develop and implement written policies prohibiting mistreatment, neglect, and abuse of residents as required by regulation. This deficiency is related to F610.
Report Facts
Facility census: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Volkmark | Administrator | Signed the statement of deficiencies and plan of correction |
| Director of Nursing (DON) | Named in findings related to failure to suspend accused employee and investigation procedures |
Inspection Report
Abbreviated Survey
Census: 50
Deficiencies: 2
Date: Jun 3, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey was conducted to assess the facility's infection prevention and control program compliance related to COVID-19 protocols.
Findings
The facility was found to be in compliance with federal infection control regulations except for failures in staff adherence to infection control protocols, including improper mask storage, inadequate hand hygiene, and failure to sanitize medical equipment between resident uses.
Deficiencies (2)
F880 Infection Prevention & Control: Facility staff failed to follow infection control protocols for COVID-19, including improper mask storage, failure to perform hand hygiene between resident contacts, and failure to sanitize medical equipment between uses.
A4085 Infection Control/Communicable Disease: Facility failed to report communicable diseases to the state health division within seven days as required by state regulation.
Report Facts
Census: 50
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 2
Date: Feb 24, 2020
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure adequate supervision and prevention of accidents for a resident.
Complaint Details
The complaint investigation substantiated that the facility did not provide adequate supervision and care to prevent accidents, specifically related to the use of a hot pack that caused burns to a resident. The deficiency was classified as Class II.
Findings
The facility failed to provide adequate care and supervision to prevent accidents for one resident, resulting in a burn injury from improper use of a hot pack. Staff lacked proper policy, training, and physician orders for the use of hot packs, leading to resident harm.
Deficiencies (2)
F689 Free of Accident Hazards/Supervision/Devices: Facility staff failed to ensure one resident received care and treatment to prevent accidents, including improper use of a hot pack causing burns. Staff lacked proper policy, procedures, and physician orders for hot pack use.
A4073 Protective Oversight, Voluntary Leave: Facility failed to provide twenty-four hour protective oversight and supervision for residents on voluntary leave, as referenced by deficiency F689.
Report Facts
Facility census: 50
Medication dosage: 500
Wound measurement: 6.5
Wound measurement: 4.5
Wound measurement: 0.1
Wound measurement: 5.8
Wound measurement: 5.5
Wound measurement: 8
Wound measurement: 7.4
Wound measurement: 3.9
Wound measurement: 1.6
Wound measurement: 1.6
Wound measurement: 0.3
Wound measurement: 0.1
Hydrocollator temperature: 162
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Volkart | Administrator | Signed and dated the deficiency and plan of correction documents |
| Assistant Director of Nursing | Notified about resident's wounds and involved in wound care |
Inspection Report
Renewal
Deficiencies: 0
Date: Oct 18, 2019
Visit Reason
The inspection was conducted as a licensure inspection to assess compliance with health facility regulations and state licensure requirements.
Findings
No health facility survey deficiencies or state licensure deficiencies were cited as a result of this inspection.
Inspection Report
Life Safety
Census: 44
Capacity: 120
Deficiencies: 2
Date: Oct 18, 2019
Visit Reason
The inspection was conducted as a Life Safety Code survey to assess compliance with fire safety regulations and sprinkler system maintenance.
Findings
The facility failed to maintain the sprinkler system and ensure all doors leading to corridors were solid and resistant to smoke passage. Several sprinklers were corroded or painted, and corridor doors had gaps allowing smoke passage, posing a risk to all facility occupants.
Deficiencies (2)
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain sprinklers free of foreign materials and corrosion, with several sprinklers corroded or painted, risking system failure in an emergency.
K363 Corridor - Doors: Facility staff failed to ensure corridor doors were solid and resisted smoke passage, with gaps observed in multiple resident room doors.
Report Facts
Facility census: 44
Facility census: 47
Total capacity: 120
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 2
Date: Aug 6, 2019
Visit Reason
The inspection was conducted in response to allegations of resident sexual abuse reported at Adams Street - A Stonebridge Community.
Complaint Details
The complaint involved an allegation of sexual abuse by a Certified Nurse Aide (CNA) towards Resident #1. The allegation was investigated but not substantiated. The facility failed to report the allegation to the Department of Health and Senior Services within the required two-hour timeframe.
Findings
The facility failed to report an allegation of employee to resident sexual abuse within the required time frame. The investigation did not substantiate the allegation, but the facility did not notify the Department of Health and Senior Services within two hours as required.
Deficiencies (2)
F609: The facility failed to report an allegation of employee to resident sexual abuse within the required two-hour timeframe as mandated by federal regulations.
A8025: The administrator or employee failed to immediately report or cause a report to be made to the department when there was reasonable cause to believe a resident was abused or neglected.
Report Facts
Census: 51
Inspection Report
Annual Inspection
Census: 50
Deficiencies: 8
Date: Sep 20, 2018
Visit Reason
Annual inspection survey conducted at Adams Street - A Stonebridge Community to assess compliance with federal and state regulations.
Findings
The facility was found deficient in multiple areas including personal privacy, care plan timing and revision, free from accident hazards, infection control, medication management, nurse staffing information, and food safety. Several residents' rights and care plan requirements were not met as evidenced by observations and record reviews.
Deficiencies (8)
F583 Personal Privacy/Confidentiality of Records: Facility staff failed to maintain residents' privacy by not knocking and announcing themselves before entering resident rooms for five residents.
F657 Care Plan Timing and Revision: Facility staff failed to update care plans with changes in residents' needs for five residents.
F689 Free of Accident Hazards/Supervision/Devices: Facility failed to ensure the environment was free of accident hazards by leaving razors, chemicals, and medication carts unsecured.
F732 Posted Nurse Staffing Information: Facility failed to post accurate nurse staffing data and maintain required records for a minimum of 18 months.
F758 Free from Unnecessary Psychotropic Medications/PRN Use: Facility failed to perform required gradual dose reductions and limit PRN psychotropic medication orders to 14 days for two residents.
F759 Free of Medication Error Rates 5 Percent or More: Facility failed to supervise medication administration resulting in a 12% error rate for 25 medications observed.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: Facility failed to store food properly, resulting in use of expired and improperly stored food items.
F880 Infection Prevention & Control: Facility failed to establish and maintain an infection control program and failed to remove soiled gloves and contaminated linens properly.
Report Facts
Facility census: 50
Medication error rate: 12
Medication error threshold: 5
PRN psychotropic medication order limit: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Smith | Administrator | Named in relation to privacy deficiency and plan of correction |
| Jane Doe | Director of Nursing | Named in relation to care plan and medication supervision deficiencies |
Inspection Report
Life Safety
Census: 50
Capacity: 120
Deficiencies: 4
Date: Sep 20, 2018
Visit Reason
Life Safety Code survey conducted to assess compliance with fire safety and emergency preparedness regulations.
Findings
The facility failed to maintain sprinkler systems according to NFPA standards, had unsealed penetrations in smoke barrier walls, lacked functioning exhaust ventilation in resident toilet rooms, and failed to conduct fire drills quarterly on each shift as required.
Deficiencies (4)
K353 Sprinkler System - Maintenance and Testing: The facility staff failed to maintain sprinklers for one wet pipe sprinkler system in accordance with NFPA 25 and NFPA 13 standards. Wooden shelves and personal items obstructed sprinkler deflectors, reducing clearance and potentially affecting system performance.
K372 Subdivision of Building Spaces - Smoke Barrier: Facility staff failed to maintain five of ten smoke barrier walls with a one-half hour fire resistance rating. Observations showed multiple unsealed penetrations in smoke barrier walls allowing potential smoke passage.
K521 HVAC: Facility staff failed to provide functioning exhaust ventilation units in 10 resident room toilet rooms, potentially affecting all occupants of the 400 hall.
K712 Fire Drills: Facility staff failed to conduct fire drills quarterly on each shift from September 2017 through August 2018, risking delayed response procedures in the event of fire.
Report Facts
Facility census: 50
Total capacity: 120
Number of resident room toilet rooms without functioning exhaust ventilation: 10
Number of fire drills conducted: 2
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