Inspection Reports for
Stonebridge At Montgomery Health Care Center
100 Hollinshead Spring Road, Skillman, NJ, 08558
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
13 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
150% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
66% occupied
Based on a February 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Notice
Deficiencies: 0
Date: Nov 20, 2025
Visit Reason
This document serves as a Notice of Privacy Practices informing individuals about how their medical information may be used and disclosed by NJDHSS, and describing their rights related to this information.
Findings
The notice explains the types of information covered, reasons for use and disclosure of health information, individuals' rights regarding their health information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director | NJDHSS Privacy Officer named as contact for privacy practices |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 25, 2025
Visit Reason
The inspection was conducted in response to complaint NJ 175572 regarding failure to ensure thorough investigations of abuse or neglect for three residents with wounds or falls.
Complaint Details
Complaint NJ 175572 alleged failure to ensure abuse or neglect investigations for three residents with wounds or falls. The complaint was substantiated with findings of inadequate investigations and documentation.
Findings
The facility failed to conduct thorough investigations for Resident #147 who developed a new stage 3 pressure ulcer identified during an outpatient visit, Resident #25 who sustained an unwitnessed fall resulting in head injury and hospital transfer, and Resident #44 who sustained unwitnessed falls with skin tears. Documentation and wound measurements were incomplete and investigations lacked comprehensive staff statements and causal factor analysis.
Deficiencies (3)
Failure to investigate and measure a new stage 3 pressure ulcer on Resident #147's left hip identified during an outpatient wound care visit.
Failure to conduct a thorough investigation of Resident #25's unwitnessed fall resulting in head trauma and hospital transfer.
Failure to fully investigate Resident #44's unwitnessed falls with skin tears and blood at bedside.
Report Facts
Date of inspection: Jun 25, 2025
Stage 3 pressure ulcer measurement: No documented measurements for Resident #147's stage 3 pressure ulcer
Fall date: Jun 2, 2025
Skin tear measurement: 1.1
Skin tear measurement: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN #1) | Interviewed regarding skin assessments and fall incident documentation | |
| Licensed Practical Nurse/Unit Manager (LPN/UM) | Interviewed regarding skin assessments, wound care, and documentation practices | |
| Director of Nursing (DON) | Interviewed regarding wound investigations and fall incident investigations | |
| Licensed Nursing Home Administrator (LNHA) | Participated in meetings discussing investigation findings | |
| Regional Nurse | Interviewed regarding skin assessments and CNA reporting | |
| Charge Nurse (CN) | Provided investigation documentation for Resident #25's fall |
Inspection Report
Routine
Deficiencies: 10
Date: Jun 25, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident care, safety, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure call light accessibility for residents, failure to timely report injuries and conduct thorough investigations of falls and injuries, failure to prevent pressure ulcers, inadequate fall prevention and supervision, improper food storage and kitchen sanitation, incomplete medical record documentation, failure to follow hand hygiene protocols, and lack of a water safety management program for Legionella prevention.
Deficiencies (10)
Call lights were not accessible to residents in their rooms, including 7 of 15 residents reviewed.
Failure to timely report injuries of unknown origin and suspected abuse to the New Jersey Department of Health for 3 residents.
Failure to conduct thorough investigations of falls and injuries for 3 residents, including failure to obtain statements and identify causal factors.
Failure to submit Minimum Data Set (MDS) assessments within required timeframes for 3 residents.
Failure to provide appropriate pressure ulcer care and prevent new ulcers, including failure to document and measure a Stage 3 pressure ulcer for one resident.
Failure to adequately monitor and supervise residents at high risk for falls, resulting in multiple falls with injuries including fractures and intracranial bleeding.
Failure to maintain kitchen equipment and environment in a clean and sanitary manner, including soiled ceiling tiles, debris on racks and floors, exposed food, and malfunctioning dish machine.
Failure to follow appropriate hand hygiene during meal service by staff, increasing risk of infection transmission.
Failure to maintain a water safety management program including Legionella testing and prevention measures.
Failure to accurately document medical care and interventions for a resident experiencing respiratory distress requiring hospital transfer.
Report Facts
Residents reviewed for call light accessibility: 15
Residents reviewed for injury reporting: 3
Residents reviewed for investigations: 3
Residents with late MDS assessments: 3
Pressure ulcer stage 3 size: 4.5
Fall risk assessment scores: 13
Dish machine wash temperature: 149
Resident falls: 9
Skin tear size: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in call light accessibility and fall supervision findings for Resident #15 |
| DON | Director of Nursing | Named in multiple findings including injury reporting, fall investigations, wound care, and medical record documentation |
| LNHA | Licensed Nursing Home Administrator | Named in multiple findings including injury reporting, fall investigations, wound care, infection control, and water safety |
| LPN/UM | Licensed Practical Nurse/Unit Manager | Named in call light accessibility, hand hygiene, and wound care findings |
| CNA #3 | Certified Nurse Aide | Named in skin tear incident during care for Resident #1 |
| HFS | Healthcare Food Service Supervisor | Named in hand hygiene and food service findings |
| ADD | Assistant Director of Dining | Named in kitchen sanitation and hand hygiene findings |
| EC | Executive Chef | Named in kitchen sanitation and dish machine temperature findings |
| UM | Unit Manager | Named in call light accessibility and fall supervision findings |
| RN #1 | Registered Nurse | Named in fall investigations and injury reporting |
| RN #2 | Registered Nurse | Named in skin tear incident and respiratory distress documentation |
| DSS | Director of Social Services | Named in skin tear incident investigation |
| HD | Housekeeping Director | Named in Legionella prevention program findings |
Inspection Report
Routine
Deficiencies: 5
Date: Feb 6, 2024
Visit Reason
The inspection was conducted to assess compliance with food safety and storage regulations in the facility's kitchen and food preparation areas.
Findings
The facility failed to properly label, date, and store potentially hazardous foods, maintain kitchen equipment to prevent microbial growth, and maintain multiuse food-contact surface cutting boards to prevent microbial growth. Several violations were observed including unlabeled food containers, improper storage of wet nested items, and damaged cutting boards.
Deficiencies (5)
Failure to label or date a 22-quart plastic food storage container containing rice soup.
Opened 20-pound box of wax beans improperly stored open to air.
Wet nested stainless steel mixing bowls and plastic food storage containers stored improperly.
Four cutting boards with scrapes, gouges, and black discoloration not properly maintained.
One-pound bag of cereal in emergency food supply room not labeled or dated.
Report Facts
Food container size: 22
Box weight: 20
Bag weight: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Dining Services | Provided observations and statements regarding food storage and labeling deficiencies | |
| Assistant Director of Dining Services | Observed unlabeled cereal bag and stated it should be labeled | |
| Licensed Nursing Home Administrator | Stated the facility had a new dining company and were working out issues |
Inspection Report
Annual Inspection
Census: 33
Capacity: 50
Deficiencies: 8
Date: Feb 6, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to food procurement and safety, including improper labeling and storage of food items, and life safety code violations including egress door locking, emergency lighting, sprinkler system maintenance, corridor door closures, and gas equipment storage.
Deficiencies (8)
Food Procurement, Store/Prepare/Serve-Sanitary - failed to label, date, and store potentially hazardous foods appropriately to prevent food borne illness and maintain kitchen equipment to prevent microbial growth.
Egress Doors - failed to ensure 15-second delayed egress feature on exit door functioned properly.
Emergency Lighting - failed to provide battery back-up emergency light above interior emergency generator transfer switch.
Hazardous Areas - Enclosure - failed to ensure fire-rated doors to hazardous areas were self-closing, labeled, and separated by smoke resisting partitions.
Sprinkler System - Maintenance and Testing - failed to maintain all parts of automatic sprinkler system in optimal condition.
Corridor Doors - failed to ensure corridor doors resisted passage of smoke and ensured complete bedroom door closure for smoke/fire confinement.
Electrical Systems - Essential Electric System - failed to ensure remote manual stop station for interior diesel generator was installed.
Gas Equipment - Cylinder and Container Storage - failed to prohibit combustible storage within 5 feet of quantities of oxygen exceeding 300 cubic feet.
Report Facts
Census: 33
Total Capacity: 50
Deficiencies cited: 8
Date survey completed: Feb 6, 2024
Plan of correction completion date: Mar 11, 2024
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Sep 9, 2021
Visit Reason
The inspection was conducted due to complaints and investigations related to failure to report injuries, failure to conduct thorough investigations of injuries of unknown origin, improper resident transfers causing injury, and infection control deficiencies.
Complaint Details
The complaint investigation focused on Resident #14 regarding failure to report injuries, failure to investigate injuries properly, and improper transfer causing injury. The investigation included interviews with staff, review of incident reports, hospital records, and facility policies. The facility admitted to not reporting injuries since November 2020 and improper transfer by a CNA resulting in hospitalization. Disciplinary actions and staff in-service trainings were noted post-incident.
Findings
The facility failed to timely report injuries of unknown origin for a resident, failed to complete thorough investigations related to injuries, improperly transferred a resident causing significant injury requiring hospitalization, and failed to maintain proper infection control and food safety standards.
Deficiencies (5)
Failure to timely report three injuries of unknown origin to the New Jersey Department of Health for Resident #14.
Failure to complete a thorough investigation related to an injury of unknown origin for Resident #14.
Failure to ensure proper transfer technique and adequate staff assistance during transfer of Resident #14, resulting in significant bruising, hematoma, pain, and hospitalization.
Failure to properly handle and store potentially hazardous foods, maintain kitchen equipment and areas to prevent microbial growth and cross contamination.
Failure to maintain infection control standards during wound care treatment for Resident #2, including improper use of gloves and cleaning techniques.
Report Facts
Incident dates: 3
Bruise size: 12
Bruise size: 7
Bruise size: 0
Incident report time: 72
Incident report time: 24
Weight of food items: 18.75
Weight of food items: 20
Weight of food items: 18
Weight of canned food: 6.625
Number of ice cream containers: 3
Number of individual dessert containers: 45
Number of meat patties: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Transferred Resident #14 alone using Sit to Stand device causing injury | |
| Director of Nursing (DON) | Interviewed regarding failure to report injuries and improper transfer incident | |
| Administrator | Conducted investigation of Resident #14 injury and disciplinary action for CNA | |
| Registered Nurse (RN) | Provided wound care to Resident #2 with improper infection control technique | |
| Food Service Director (FSD) | Acknowledged food safety and sanitation deficiencies in kitchen | |
| Executive Chef (EC) | Acknowledged food labeling and storage deficiencies in kitchen | |
| Director of Rehabilitation (DOR) | Provided therapy assessment and transfer recommendations for Resident #14 |
Inspection Report
Annual Inspection
Census: 31
Deficiencies: 8
Date: Sep 9, 2021
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to failure to report injuries of unknown origin, failure to investigate and prevent alleged violations, improper resident transfer causing injury, improper food handling and storage, failure to maintain infection control standards during treatment, failure to maintain minimum staffing ratios, and life safety code violations including emergency lighting and fire extinguisher maintenance.
Deficiencies (8)
Failure to report three injuries of unknown origin to the New Jersey Department of Health for Resident #14.
Failure to complete a thorough investigation related to an injury of unknown origin for Resident #14.
Failure to ensure resident was transferred using correct mechanical lift device and sufficient staff assistance, resulting in injury to Resident #14.
Failure to properly handle and store potentially hazardous foods and maintain kitchen equipment to prevent microbial growth and cross contamination.
Failure to maintain infection control standards during wound treatment for Resident #2, including improper glove use and hand hygiene.
Failure to maintain required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey.
Failure to provide battery backup emergency lighting above the emergency generator's transfer switch independent of the building's electrical system and emergency generator.
Failure to perform and document monthly visual examination of fire extinguishers on two of 25 extinguishers.
Report Facts
Census: 31
Staffing noncompliance dates: 9
Fire extinguishers inspected: 25
Fire extinguishers with missing monthly inspection documentation: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in relation to failure to report injuries and failure to investigate allegations | |
| Administrator | Named in relation to failure to report injuries and staffing issues | |
| Certified Nursing Assistant | CNA | Named in relation to improper resident transfer causing injury |
| Registered Nurse | RN | Named in relation to infection control deficiency during wound treatment |
| Director of Facilities Services | Named in relation to emergency lighting and fire extinguisher maintenance | |
| Director of Rehabilitation | Named in relation to resident transfer and therapy recommendations |
Inspection Report
Routine
Census: 26
Deficiencies: 0
Date: Jan 11, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
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