Inspection Reports for
StoneBridge Senior Living Oak Tree

The inspection identified multiple deficiencies related to respiratory care, food safety, nursing assistant training, clinical records, waste management, and infection control. The facility failed to maintain proper cleaning and maintenance of CPAP machines, food storage and labeling, and staff training compliance.

The facility failed to maintain the fire alarm system control panel secured against unauthorized access, did not provide complete and verifiable documentation of quarterly fire drills, and failed to post required oxygen storage precautionary signage. These deficiencies have the potential to affect all facility occupants.

The facility failed to obtain physician orders and properly clean and maintain CPAP machines for residents, failed to store and handle food safely including improper hand hygiene and food storage practices, failed to allow sanitized dishes to air dry before stacking, and failed to properly contain waste and refuse to prevent pest harboring.

The facility failed to ensure that an employee with criminal convictions related to controlled substances was not employed with access to controlled substances. The facility also lacked required written statements signed by licensed physicians for several staff and failed to obtain signatures on individualized service plans from residents or their legal representatives. Additionally, the facility did not allow sanitized dishes to air dry properly before storage.

The complaint investigation found that the facility did not notify the resident's physician or emergency contact until the day after the incident. Interviews with staff and the physician confirmed delayed assessment and notification despite the resident's pain and swelling. The physician expected prompt notification for timely assessment and treatment.

The facility failed to promptly notify the resident's physician and family after the resident's leg fell from the wheelchair pedal causing a fracture. Staff delayed assessment and notification despite the resident showing pain, swelling, and bruising.

The complaint investigation was substantiated. The facility failed to notify the resident's physician and family promptly after the resident's leg injury caused by a wheelchair pedal. The resident required additional assessment and treatment, which was delayed due to lack of timely notification.

The facility failed to promptly notify the resident's physician and emergency contact after the resident sustained a leg injury. Interviews and record reviews confirmed delays in assessment, notification, and documentation related to the incident.

The investigation was complaint-driven, triggered by allegations of resident mistreatment, privacy breaches, failure to follow professional care standards, medication errors, unsafe environment, food safety violations, and improper arbitration agreement disclosures. The census at the time was 30 residents.

The facility was found deficient in multiple areas including resident dignity and respect, privacy violations, failure to complete neurological assessments and incident reports after falls, medication administration errors, unsecured treatment and shower rooms, unsafe medication storage, poor kitchen hygiene and food storage practices, malfunctioning dishwashing machine, and inadequate explanation of arbitration agreements.

The facility failed to conduct required monthly functional tests of emergency lighting fixtures and failed to maintain clear access and working space around electrical panels. Additionally, the facility did not maintain complete and verifiable documentation of weekly generator inspections, transfer switch tests, and load tests.

The complaint investigation found that staff did not document administering a Fentanyl patch and failed to remove the old patch, leading to the resident having two patches simultaneously. The resident experienced symptoms consistent with opioid overdose and was hospitalized. The physician confirmed the risk of overdose from multiple patches.

The facility failed to document administration of a Fentanyl patch and did not remove the previous patch before applying a new one, resulting in two patches being on the resident simultaneously. This led to a potential opioid overdose requiring hospital intervention.

The facility failed to meet professional standards in medication administration as staff did not properly document the removal and application of fentanyl patches, leading to potential overdose risks. The Director of Nursing was responsible for oversight but was unsure of the frequency of staff documentation.

The facility failed to conduct the required monthly fire drills on each shift every three months and did not maintain the sprinkler system inspections and certifications as required by NFPA 25, 1998 edition.

The facility failed to maintain the complete fire alarm system, provide required one-hour fire separation for a furnace room, and maintain the sprinkler system inspections and certifications as required by NFPA standards. These deficiencies affect all 55 residents present at the time of inspection.

The facility failed to report an allegation of resident physical abuse within the required two-hour timeframe and did not conduct a thorough investigation of the allegation. Staff did not document an assessment of the resident's skin or interview the resident or involved staff during the investigation.

The facility was found deficient in multiple areas including failure to screen new employees through the Nurse Aide Registry, incomplete assessments and consents for bedrails, improper management of psychotropic medications, inadequate infection control practices, and failure to ensure proper hand hygiene and food safety procedures.

The facility failed to maintain unobstructed exit doors, conduct fire drills as required, and properly inspect and test essential electrical systems. These deficiencies have the potential to delay evacuation and affect all facility occupants.

The facility failed to ensure staff properly washed their hands and removed gloves between tasks, leading to potential cross-contamination. Observations and interviews confirmed repeated failures in hand hygiene practices by dietary aides.

The visit was complaint-related, triggered by allegations of failure to properly screen employees, improper use of bed rails, medication management issues, hand hygiene lapses, inadequate tuberculosis screening, and lack of a certified infection preventionist. Substantiation status is not explicitly stated.

The facility failed to screen new employees against the Nurse Aide Registry prior to employment, did not complete required assessments and obtain consents for bed rail use for multiple residents, failed to perform gradual dose reductions for psychotropic medications and document clinical rationale, allowed dietary staff to handle clean and dirty dishes without proper hand hygiene, failed to complete timely and documented tuberculosis screenings for employees, and lacked a certified infection preventionist on staff.

The facility failed to meet professional standards in medication management, including failure to discard expired medications, failure to transcribe physician orders correctly, and failure to administer physician-ordered medications. Additionally, the facility failed to ensure psychotropic medication orders were limited to 14 days unless clinically justified and failed to obtain appropriate diagnoses for antipsychotic medication use.

The facility failed to provide initial and annual training and testing on emergency preparedness policies and procedures to staff during the 12-month review period. This failure has the potential to delay staff response in an emergency and affect all facility occupants.

The complaint investigation was substantiated as the facility failed to report and investigate abuse allegations between residents and did not prevent further abuse. The facility also failed to comply with food safety and bed rail safety regulations.

The facility failed to report witnessed resident-to-resident abuse and did not follow proper procedures for investigating and preventing further abuse. Staff failed to intervene and document incidents involving residents #1 and #25. Additionally, the facility failed to maintain food safety and bed rail safety standards.

The facility failed to develop adequate emergency preparedness policies, conduct required fire drills, and maintain fire doors and egress exit doors. Deficiencies were found in subsistence needs, emergency communication plans, fire drill execution, and door inspections.

The facility failed to store food properly to prevent contamination and used expired foods. Staff did not maintain a chemical sanitation test kit for the dishwasher, and multiple food safety violations were observed including improper handwashing and food storage practices.