CONCORD, CA - Federal health inspectors documented multiple compliance failures at Stonebrook Healthcare Center during a March 2025 survey, including lapses in infection control practices, incomplete mental health screenings, and delayed dental care coordination.
Infection Prevention Protocols Not Followed During Patient Care
Inspectors observed nursing staff repeatedly failing to follow the facility's own infection control policies when caring for residents with invasive medical devices and open wounds. The violations centered on a breakdown in what healthcare professionals call "enhanced barrier precautions" - specialized infection prevention measures required when residents have feeding tubes, catheters, or wounds.
In one documented case, two licensed vocational nurses changed a resident's gastrostomy tube without wearing protective gowns, despite facility policy requiring full barrier precautions for any care involving feeding tubes. During the same procedure, one nurse removed contaminated gloves and immediately donned clean gloves without performing hand hygiene between the glove changes - a fundamental infection control principle designed to prevent cross-contamination.
The facility's own policy, reviewed in January 2025, specifically mandates enhanced barrier precautions during "device care or use" including feeding tubes, and requires hand hygiene "after removing gloves." When questioned about the observations, both nurses acknowledged they should have worn gowns during the procedure.
Healthcare facilities implement enhanced barrier precautions because residents with invasive devices face significantly elevated infection risks. Feeding tubes create direct pathways into the gastrointestinal system, bypassing the body's natural protective barriers. Without proper gown and glove use during care activities, healthcare workers can inadvertently transfer bacteria from contaminated surfaces or other patients to vulnerable sites. The failure to perform hand hygiene between glove changes compounds this risk, as gloves can develop microscopic tears or become contaminated during removal.
In a separate incident, inspectors observed a licensed vocational nurse performing wound care on a resident's deep tissue pressure injury without performing hand hygiene when changing gloves mid-procedure. The resident had an order for daily wound cleaning with sterile water and specialized dressing application. When confronted with the observation, the nurse confirmed that hand hygiene should occur before and after glove changes, acknowledging the lapse.
The infection control failures extended beyond direct patient care. Inspectors found respiratory equipment for one resident with chronic obstructive pulmonary disease stored improperly on multiple days. A CPAP mask was repeatedly observed lying exposed on top of the machine, and a nebulizer mask was left uncovered on the bedside table - both when not in use. According to the facility's infection preventionist, respiratory masks should be stored in designated infection prevention bags after each use to prevent microbial contamination.
CPAP and nebulizer masks come into direct contact with residents' airways and face. When left exposed to environmental contaminants rather than stored in clean protective bags, these devices can harbor bacteria and fungi that residents then inhale during subsequent use. For individuals with compromised respiratory function, such exposures can trigger respiratory infections or exacerbate existing conditions.
Bed Rail Assessments Not Completed Before Installation
The facility placed bed rails on residents without first conducting required safety assessments to determine whether the devices were appropriate and safe for individual use. Inspectors identified two residents with quarter rails or bed canes installed on their beds despite having no documented evaluation by the facility's rehabilitation department.
Both residents had severe cognitive impairment and required substantial or maximal assistance for bed mobility and transfers. One resident had been using quarter rails since at least early 2023, while the second resident had bed canes on both sides of the bed's upper portion. Certified nursing assistants reported the devices were used for positioning during care provision.
The facility's own policy from January 2025 requires assessments "to determine the resident's symptoms or reason for using bed rails" at admission, readmission, quarterly intervals, and upon status changes. The Director of Rehabilitation confirmed that full evaluations should occur before bed rail installation but stated she did not believe either resident had been properly assessed.
Bed rails present documented entrapment and injury risks, particularly for residents with cognitive impairment who may not understand how to safely use the devices. Federal regulations require facilities to assess individual risks and benefits, obtain informed consent, and try alternative approaches before resorting to bed rails. The assessment process evaluates whether a resident can safely operate the rails, whether they might attempt to climb over them, and whether gaps between the rail and mattress could cause entrapment.
During interviews, facility leadership acknowledged systemic failures across multiple departments - including maintenance, therapy, and nursing - in the bed rail evaluation process. The Administrator stated that residents without completed assessments should not have bed rails in use, and the Director of Nursing acknowledged he was unaware of the extent of the problem.
Mental Health Screening Requirements Not Met
The facility failed to refer a resident for required specialized mental health evaluation after the resident received a new diagnosis of major depressive disorder with psychotic symptoms in January 2023. Federal regulations require nursing homes to refer residents to state-designated authorities for Level II PASARR (Preadmission Screening and Resident Review) evaluations when serious mental disorders are newly identified.
The resident had originally been admitted in 2015 with a diagnosis of bipolar disorder. When the resident's condition evolved to include major depressive disorder with psychotic symptoms nearly eight years later, no new PASARR screening was initiated. The resident's care plan addressed depression with interventions focused on medication administration, but the specialized evaluation mandated by federal law never occurred.
PASARR evaluations serve a specific protective function: they determine whether a nursing home can appropriately meet a resident's specialized mental health needs, or whether the individual requires services available only in psychiatric facilities. The evaluations also ensure that care plans incorporate specialized mental health interventions beyond basic medication management.
The facility's receptionist, who was responsible for the PASARR process, stated she was unaware that new screenings were required when residents received new mental illness diagnoses. The Administrator confirmed that policy required new PASARR evaluations in such circumstances.
Dental Care Coordination Delayed for Months
Social services staff failed to provide timely follow-up after a resident's dental insurance denied coverage for replacement dentures, leaving the resident with ill-fitting lower partial dentures for more than five months. The resident's dental evaluation in September 2024 identified the fit problem, and the facility's contracted dentist recommended new dentures.
However, when the resident's Medicaid plan denied the claim in late September 2024, documented follow-up ceased. Physician progress notes from November 2024 recorded that the resident reported hearing nothing from the Director of Social Services about the denial, despite the dentist having informed the resident that denture care was not covered. The physician documented a conversation with social services directing staff to either work with the existing dentist or help the resident find another provider who would accept Medicaid coverage.
By January 2025, the resident was informed that social services would investigate coverage options and locate a different dentist, but no resolution had occurred by the time of the March inspection. When interviewed, the resident stated the social services director "kept telling them that she was taking care of their dentures but never did."
Properly fitting dentures are not merely cosmetic devices - they directly impact nutritional status and overall health. Ill-fitting dentures cause pain during chewing, limit food choices to soft items that require less mastication, and can lead to inadequate caloric and protein intake. For nursing home residents who may already face nutritional challenges, prolonged inability to wear lower dentures compounds health risks.
The facility's job description for the social services position specifically requires staff to "assist in obtaining resources from community social, health and welfare agencies to meet the needs of the resident." The Director of Social Services acknowledged awareness of the denture problem but stated she could not recall whether she had documented follow-up interactions with the resident. She also confirmed the facility had no dental care policy or procedure to guide such coordination efforts.
Additional Issues Identified
Beyond these major violations, inspectors documented that the facility lacked written procedures for proper storage of respiratory equipment, contributing to the improper storage practices observed during the survey. Multiple staff members across different shifts demonstrated inconsistent understanding of infection control requirements, suggesting gaps in training or supervision. The Administrator acknowledged being unaware of the scope of several problems, including the extent of bed rails in use without proper assessments.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Stonebrook Healthcare Center from 2025-03-06 including all violations, facility responses, and corrective action plans.
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