ElderGrade

Inspection citations at Stoneybrook Retirement Community

32 citations on record, 1 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2026 9 0
2024 3 0
2023 20 1
C May 14, 2026 Tag F0908 Complaint investigation Corrected Jun 2026

Environmental Deficiencies

Keep all essential equipment working safely.

No actual harm, minimal potential

D May 14, 2026 Tag F0880 Complaint investigation Corrected Jun 2026

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

D May 14, 2026 Tag F0761 Complaint investigation Corrected Jun 2026

Pharmacy Service Deficiencies

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.

No actual harm, potential for more than minimal harm

D May 14, 2026 Tag F0760 Complaint investigation Corrected Jun 2026

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

No actual harm, potential for more than minimal harm

D May 14, 2026 Tag F0692 Complaint investigation Corrected Jun 2026

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

No actual harm, potential for more than minimal harm

D May 14, 2026 Tag F0677 Complaint investigation Corrected Jun 2026

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

No actual harm, potential for more than minimal harm

D May 14, 2026 Tag F0656 Corrected Jun 2026

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

D May 14, 2026 Tag F0628 Complaint investigation Corrected Jun 2026

Resident Rights Deficiencies

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

No actual harm, potential for more than minimal harm

F May 14, 2026 Tag F0727 Complaint investigation Corrected Jun 2026

Nursing and Physician Services Deficiencies

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.

No actual harm, potential for more than minimal harm

D June 24, 2024 Tag F0758 Complaint investigation Corrected Jul 2024

Pharmacy Service Deficiencies

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.

No actual harm, potential for more than minimal harm

D June 24, 2024 Tag F0689 Complaint investigation Corrected Jul 2024

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

D June 24, 2024 Tag F0625 Complaint investigation Corrected Jul 2024

Resident Rights Deficiencies

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

No actual harm, potential for more than minimal harm

D November 14, 2023 Tag F0687 Complaint investigation Corrected Dec 2023

Quality of Life and Care Deficiencies

Provide appropriate foot care.

No actual harm, potential for more than minimal harm

D November 14, 2023 Tag F0684 Complaint investigation Corrected Dec 2023

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D November 14, 2023 Tag F0655 Complaint investigation Corrected Dec 2023

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

No actual harm, potential for more than minimal harm

D April 5, 2023 Tag F0849 Corrected May 2023

Administration Deficiencies

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.

No actual harm, potential for more than minimal harm

D April 5, 2023 Tag F0761 Corrected May 2023

Pharmacy Service Deficiencies

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.

No actual harm, potential for more than minimal harm

D April 5, 2023 Tag F0745 Corrected May 2023

Quality of Life and Care Deficiencies

Provide medically-related social services to help each resident achieve the highest possible quality of life.

No actual harm, potential for more than minimal harm

D April 5, 2023 Tag F0740 Corrected May 2023

Quality of Life and Care Deficiencies

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

No actual harm, potential for more than minimal harm

D April 5, 2023 Tag F0726 Corrected May 2023

Nursing and Physician Services Deficiencies

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.

No actual harm, potential for more than minimal harm

D April 5, 2023 Tag F0695 Corrected May 2023

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

No actual harm, potential for more than minimal harm

D April 5, 2023 Tag F0690 Corrected May 2023

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

No actual harm, potential for more than minimal harm

D April 5, 2023 Tag F0684 Corrected May 2023

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D April 5, 2023 Tag F0677 Corrected May 2023

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

No actual harm, potential for more than minimal harm

D April 5, 2023 Tag F0656 Corrected May 2023

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

D April 5, 2023 Tag F0582 Corrected May 2023

Resident Rights Deficiencies

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

No actual harm, potential for more than minimal harm

D April 5, 2023 Tag F0580 Corrected May 2023

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

No actual harm, potential for more than minimal harm

D April 5, 2023 Tag F0550 Corrected May 2023

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

No actual harm, potential for more than minimal harm

F April 5, 2023 Tag F0882 Corrected May 2023

Infection Control Deficiencies

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

No actual harm, potential for more than minimal harm

F April 5, 2023 Tag F0880 Corrected May 2023

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

F April 5, 2023 Tag F0865 Corrected May 2023

Administration Deficiencies

Have a plan that describes the process for conducting QAPI and QAA activities.

No actual harm, potential for more than minimal harm

J April 5, 2023 Tag F0689 Corrected Jan 2023

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Immediate jeopardy to resident health or safety

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.