A list of the most recent deficiencies for Stoneybrook Retirement Community. 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? |
|---|---|---|---|---|
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-11-14 | 2023-12-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-14 | 2023-12-14 | Y |
| Provide appropriate foot care. | Health | 2023-11-14 | 2023-12-14 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-05 | 2023-05-19 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-05 | 2023-05-19 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-04-05 | 2023-05-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-05 | 2023-05-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-05 | 2023-05-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-05 | 2023-05-19 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-04-05 | 2023-05-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-05 | 2023-05-19 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-04-05 | 2023-05-19 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-04-05 | 2023-05-19 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-04-05 | 2023-05-19 | 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 | 2023-04-05 | 2023-05-19 | 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 | 2023-04-05 | 2023-05-19 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-04-05 | 2023-05-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-05 | 2023-05-19 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-04-05 | 2023-05-19 | N |
| Install noncombustible or limited-combustible interior walls. | Fire Safety | 2023-04-12 | 2023-05-05 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-04-12 | 2023-05-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-12 | 2023-05-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-12 | 2023-05-05 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-04-12 | 2023-05-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-04-12 | 2023-05-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-12 | 2023-05-05 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-04-12 | 2023-05-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-12 | 2023-05-05 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2023-04-12 | 2023-05-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-12 | 2023-05-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-04-12 | 2023-05-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-05 | 2023-01-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-10 | 2022-09-08 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-11-09 | 2021-12-09 | 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 | 2021-11-09 | 2021-12-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-11-09 | 2021-12-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-09 | 2021-12-09 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-11-09 | 2021-12-09 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-11-09 | 2021-12-09 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-11-09 | 2021-12-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-11-09 | 2021-12-09 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-11-09 | 2021-12-09 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-11-09 | 2021-12-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-11-09 | 2021-12-09 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-09-27 | 2021-10-27 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-09-27 | 2021-10-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-27 | 2021-10-27 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-09-27 | 2021-10-27 | 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 | 2021-09-27 | 2021-10-27 | 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 | 2021-09-27 | 2021-10-27 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2019-08-06 | 2019-09-23 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-08-06 | 2019-09-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-08-06 | 2019-09-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-06 | 2019-09-23 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-08-06 | 2019-09-23 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-08-06 | 2019-09-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-08-06 | 2019-09-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-08-06 | 2019-09-23 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-08-06 | 2019-09-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-06 | 2019-09-23 | 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 | 2019-08-14 | 2019-09-14 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-08-14 | 2019-08-27 | N |
| Dispose of garbage and refuse properly. | Health | 2019-08-14 | 2019-08-27 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-08-14 | 2019-08-23 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-08-14 | 2019-08-23 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-08-14 | 2019-08-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-08-14 | 2019-08-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-14 | 2019-08-23 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-08-14 | 2019-08-23 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2019-08-14 | 2019-08-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-14 | 2019-08-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-14 | 2019-08-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-14 | 2019-08-23 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-06-06 | Not Fixed | N |
