Stonebridge Senior LLC

A complaint revisit was completed on 7/15/25 for all previous deficiencies cited on 1/9/24. A deficiency was cited.The regulations governing Assisted Living Residences were revised. The new regulation, Chapter VII, was implemented on 7/1/25. Based on record review and interview, the residence failed to evaluate a resident prior to re-admission to the residence after transfer to another health care entity, affecting one of seven sample residents (#48).This deficiency was cited previously during a state relicensure and complaint survey on 1/9/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Record ReviewResident #48 was admitted to the residence on 2/22/24 with diagnoses of edema and congestive heart failure, and later with diagnoses of streptococcal infection, pressure ulcer of the right leg, peripheral vascular disease, cellulitis of the right lower extremity, severe sepsis, and streptococcal bacteremiaProgress notes dated 6/5/25- 7/15/25 read in part:On 6/5/25, Resident #48 was sent out due to feeling sick, vomiting, and abnormal vitals.On 6/9/25, Resident #48 would likely be sent to rehabilitation due to increased weakness and to regain strength.On 6/17/25, Resident #48 returned to the residence post-rehabilitation. No changes to the care plan were made.On 7/2/25, Resident #48 complained of increased general pain and feeling nauseous. Overnight staff reported Resident #48 vomited once overnight. Resident #48 presented being lethargic, blood pressure of 99/50, and notable redness to the right leg from the foot to the back of the right thigh. Resident #48 reported not feeling well. Resident #48 was sent to the emergency department for possible sepsis.On 7/8/25, Resident #48 returned to the residence from the emergency department for infection. Resident #48 was alert and back to baseline with continued antibiotic treatment.On 7/10/25, Resident #48 presented with chills and feeling lethargic. Resident #48 agreed to go to the emergency department.On 7/12/25, Resident #48 returned from the emergency department following treatment for an infection. Resident #48 was alert, oriented, and back to baseline. External service provid..

A licensure complaint, prompted by #CO37381, was completed on 7/15/25. Deficiencies were cited.A change of ownership occurred on 1/31/25. Based on observation and interview, the residence failed to offer water to residents with every meal, affecting 18 residents residing in the secure environment. Findings include:On 7/15/25 at approximately 8:30 a.m., breakfast was being served to residents, and only juice was offered to all residents. No water was offered throughout the breakfast meal. On 7/15/25 at approximately 1:00 p.m., a family member of Resident #43 said water was not offered at meals.On 7/15/25 at approximately 4:15 p.m., the administrator said she expected water to be offered by staff to residents at all meals. Based on record review and interview, the residence failed to ensure each care plan was developed with input from the resident' s representative and detailed specific personal service needed and preferences, along with the staff tasks necessary to meet those needs, affecting one of seven sample residents (#43). (Cross-reference T2140)Findings include:Resident #43 was admitted to the residence on 3/12/19 with diagnoses including Parkinson' s disease and oropharyngeal dysphagia.A practitioner' s order, dated 8/30/24, directed the residence to cut all food into bite-sized pieces prior to serving.A care plan in Resident #43' s record, dated 6/24/25, read she did not require assistance with meal consumption and was on a regular diet.On 7/15/25 at 3:00 p.m., Staff #27 stated that Resident #43 did not have a modified diet order. She explained that the family has preferences and selected Resident #43' s food weekly. Staff #27 stated she was unaware that Resident #43 had a practitioner' s order directing the residence to cut .. Based on record review and interview, the residence failed to provide a therapeutic diet as prescribed by the resident' s authorized practitioner, affecting one of seven sample residents (#43). (Cross-reference T1150)Findings include:Resident #43 was admitted to the residence on 3/12/19 with diagnoses of dementia associated with parkinson' s disease and oropharyngeal dysphagia.A practitioner' s order, dated 8/30/24, directed the residence to cut all food into bite-sized pieces before serving.A care plan, dated 6/24/25, read in part: Resident #43 did not require assistance with meal consumption.On 7/15/25 at 8:00 a.m., Staff #1 failed to include Resident #43 in a list of residents who had modified food textures or therapeutic diets when requested.On 7/15/25 at 3:00 p.m., Staff #27 stated, Resident #43 did not have a modified diet order. She explained that the family had preferences and selected Resident #43' s food weekly. Staff #27 stated she was unaware that Resident #43 had a practitioner' s order directing t..

A complaint revisit was completed on 7/15/25 for the previous deficiency cited on 8/27/24. A deficiency was cited.The regulations governing Assisted Living Residences were revised. The new regulation, Chapter VII, was implemented on 7/1/25. Based on record review and interview, the residence failed to conduct at least one safety check for all consenting residents between 10:00 p.m. and 6:00 a.m., affecting 58 residents residing in the assisted living residence.This deficiency was cited previously during a state relicensure and complaint survey on 8/27/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:On 7/15/25 at 11:56 a.m., proof of the residence completing safety checks between 10:00 p.m. and 6:00 a.m. was requested; however, the residence was unable to provide any evidence.On 7/15/25 at 1:47 p.m., the administrator stated the residence was in the process of developing and launching a new assessment that would trigger the task in their electronic health records for the nighttime safety checks, but currently, there was no documentation for those being completed. On 7/15/25 at 4:06 p.m., the administrator explained that there was no process in place to ensure safety checks were being completed for residents who resided in the assisted living of the residence and was unsure why. She explained being unsure if the nightly safety checks were being completed for those who consented to having one, and did not have a process in place for residents who did not consent to having safety checks. The administrator reported being unsure why this deficiency was not corrected.