Deficiency Records for Stonebrook Health and Rehabilitation
Updated as of April 01, 2024
A list of the most recent deficiencies for Stonebrook Health and Rehabilitation. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-12-18 | 2024-01-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-15 | 2022-09-15 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-05-13 | 2022-05-27 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-13 | 2022-05-27 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-08-06 | 2021-08-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-06 | 2021-08-29 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-08-06 | 2021-08-27 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-08-06 | 2021-08-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-06 | 2021-08-27 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-08-06 | 2021-08-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-06 | 2021-08-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-08-06 | 2021-08-27 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-08-06 | 2021-08-27 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-08-06 | 2021-08-27 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-08-06 | 2021-08-27 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-08-06 | 2021-08-27 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2021-08-06 | 2021-08-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-06 | 2021-08-27 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-08-06 | 2021-08-27 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-08-09 | 2021-08-27 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-08-09 | 2021-08-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-09 | 2021-08-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-08-09 | 2021-08-27 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2020-02-06 | 2020-03-23 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2020-02-06 | 2020-03-23 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2020-02-06 | 2020-03-23 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2020-02-06 | 2020-03-23 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2020-02-06 | 2020-03-23 | N |
| Provide emergency officials' contact information. | Fire Safety | 2020-02-06 | 2020-03-23 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2020-02-06 | 2020-03-23 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2020-02-06 | 2020-03-23 | N |
| Implement emergency and standby power systems. | Fire Safety | 2020-02-06 | 2020-03-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-02-06 | 2020-03-23 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2020-02-06 | 2020-03-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-02-06 | 2020-03-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-06 | 2020-03-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-02-06 | 2020-03-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-06 | 2020-03-23 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2020-02-06 | 2020-03-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-02-06 | 2020-03-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-01-09 | 2020-01-31 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2020-01-09 | 2020-01-31 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-01-09 | 2020-01-31 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-01-09 | 2020-01-31 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-01-09 | 2020-01-31 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-01-09 | 2020-01-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-09 | 2020-01-31 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-01-09 | 2020-01-31 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2020-01-09 | 2020-01-31 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-01-09 | 2020-01-31 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2020-01-09 | 2020-01-31 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2020-01-09 | 2020-01-31 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-02-27 | 2019-05-09 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-02-27 | 2019-05-09 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-02-27 | 2019-05-09 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-02-27 | 2019-05-09 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-02-27 | 2019-05-09 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-02-27 | 2019-05-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-02-27 | 2019-05-09 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2019-02-27 | 2019-05-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-02-27 | 2019-05-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-02-27 | 2019-05-09 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2018-12-06 | 2018-12-31 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2018-12-06 | 2018-12-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-12-06 | 2018-12-31 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-12-06 | 2018-12-31 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-12-06 | 2018-12-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-12-06 | 2018-12-31 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-12-06 | 2018-12-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-12-06 | 2018-12-31 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-12-06 | 2018-12-31 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-12-06 | 2018-12-31 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-12-06 | 2018-12-31 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2018-12-06 | 2018-12-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-12-06 | 2018-12-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-12-06 | 2018-12-31 | N |
