Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Stonebrook Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple medical conditions developed a small discoloration near the outer right eye that a family member believed was a bruise. Nursing staff and the DON assessed the area and documented it as skin discoloration, obtained MD orders for monitoring, and added it to the care plan, but there was no documentation of how the discoloration occurred or that an investigation into an injury of unknown source was initiated. This response did not follow the facility’s abuse reporting policy, which requires thorough investigation and reporting of injuries of unknown origin.
The facility did not update or post daily nurse staffing information as required, leaving outdated staffing data displayed for an extended period. An LVN covering for the infection preventionist nurse, who was on vacation, failed to update the daily DHPPD postings, which was confirmed by both the LVN and the administrator. Facility policy requires daily posting of direct care staffing numbers for every shift.
Wet food service equipment was found stacked for storage in the kitchen, including one large baking pan and four steam table pans that had not been fully dried. The DM acknowledged the pans were still wet, and the facility’s Dish Washing P&P states dishes are to be air dried in racks before stacking and storing.
Failure to Document Alternatives Before Using Side Rails: The facility failed to document that less restrictive approaches were tried before using upper side rails for 32 residents. Observations showed the residents had both upper side rails raised, but the Siderails Screening Tool’s Alternative Measures Tried section was blank for each of them. The DON and ADON stated side rails were used based on resident preference or agreement, but the record review confirmed the required documentation of attempted alternatives was not completed.
The facility failed to maintain infection control practices in several observed situations. An RN disinfected a shared glucometer with Sani-Cloth for only a few seconds and did not know the correct 2-minute contact time, a CNA left a resident's urinary catheter bag touching the floor, and another CNA removed gloves without performing hand hygiene before handling clean bed linens. Staff interviews confirmed the improper practices, and facility policy required proper disinfection, keeping catheter drainage bags off the floor, and hand hygiene after glove removal.
A resident's ENT note was posted above the HOB in the room where it was visible to roommates and visitors. The note included the resident's full name, diagnosis of bilateral hearing loss due to cerumen impaction, and a request from the resident's daughter for the ENT MD to examine the resident's ears. The ADON confirmed the note was openly posted in the shared room, despite the facility's dignity policy stating confidential clinical information should not be openly displayed.
Failure to Document Advance Directive Status: The facility did not document Advance Directive status for two residents. No Advance Directive was found in either resident’s record, and section D of each POLST was left blank instead of indicating whether an Advance Directive was dated, unavailable, or not present. The ADON acknowledged the missing documentation, and the facility policy required Advance Directive status to be identified in the medical record.
Unlabeled GT Feeding Formula Bottle: A resident with dysphagia and a GT had Jevity 1.2 ordered via feeding pump. During observation, the formula bottle attached to the pump was not labeled or dated, and RN A confirmed it should have included the resident’s name, rate, and the date and time the feeding was started. The DON also confirmed the labeling expectations, and the facility policy required initials, date and time, and verification against the order.
Unlabeled IV Fluids: A resident receiving 0.45% Sodium Chloride IV therapy was observed with IV fluid that lacked the resident’s name, start date and time, medication instructions or IV rate, and the administering nurse’s initials. An RN confirmed the missing labels, and the NS stated the night shift nurse had started the IV without labeling or dating it, despite facility policy requiring additive labels to include the nurse’s initials, date, and time.
A resident receiving risperidone for schizophrenia was not monitored for tardive dyskinesia or other abnormal motor movements, even though the care plan identified special attention for that side effect and the consultant pharmacist noted missing psychotropic monitoring. Two residents receiving insulin lispro for DM also had no documented monitoring for signs and symptoms of hypo/hyperglycemia in their MARs or medication orders, and the LPN, RN, and DON all confirmed the monitoring was absent.
The facility failed to ensure proper storage and labeling of medications in two medication carts. An RN found an opened Lantus insulin pen with no open date, and an LVN found an unopened Procrit vial in a cart even though the label said to keep it refrigerated. The DON confirmed insulin pens should be dated when opened and refrigerated meds should not be kept in the cart when the label requires refrigeration.
A Dietary Aide did not follow the container instructions when checking the quaternary sanitizer used in the three-compartment sink. During observation, she held the test strip in the sanitizer water for about 10 to 12.54 seconds before comparing it to the chart, while the strip instructions directed staff to dip and remove, shake off excess water, wait 5 seconds, and compare.
A resident was served zucchini even though it was listed as a dislike on the meal tray ticket. During a meal observation, the resident stated she did not like the zucchini but it was still included with lunch. The DM stated the resident's preferences should be followed, and the facility policy required food preferences to be assessed and honored when possible.
Failure to re-offer pneumococcal vaccines to two residents. Records showed each resident had previously refused the vaccine, and the DSD/IP confirmed the vaccine was not offered again after admission. The facility policy required pneumococcal and influenza vaccines to be offered on admission and quarterly if eligible.
The facility did not complete and submit a required investigation summary to the state agency within five days after an alleged abuse incident between two residents, despite reporting the event to authorities. The incident involved yelling and a physical interaction, with no injuries found after assessment. Facility policy requires timely reporting of such investigations, which was not met.
The facility failed to complete and transmit discharge MDS assessments for two residents upon their discharge. One resident, with a history of pleural effusion and atrial fibrillation, and another with a left radius fracture and type two diabetes, were discharged without the required MDS assessments. Staff interviews confirmed awareness of the 14-day submission requirement, yet the assessments were not completed or submitted.
Failure to Investigate and Report Injury of Unknown Origin Near Resident’s Eye
Penalty
Summary
The facility failed to investigate and report an injury of unknown origin after a family member observed a discoloration near a resident’s outer right eye and believed it to be a bruise. The resident had diagnoses including UTI, dysarthria, and muscle wasting/atrophy, and an MDS indicating severely impaired cognition with a BIMS score of 7. During interview, the resident could not recall how the discoloration occurred. The DON stated that when the family member reported a bruise on the resident’s head, she and the ADON assessed the area with the family member present and told the family it was not a bruise but a greenish discoloration from a vein. A treatment nurse also described the area as a skin discoloration that was being monitored. Clinical documentation showed a physician order dated 12/5/25 for skin discoloration beside the outer right eye, with instructions to observe for swelling, skin breakdown, and bleeding every shift for 30 days, and a care plan problem for altered skin integrity related to this discoloration. The Weekly Non-pressure Ulcer Observation Tool documented that the family member stated it looked like a bruise and measured the discoloration as 0.5 cm by 0.1 cm. Progress notes later documented that the discoloration had resolved and that the MD was made aware, but there was no documentation explaining how the discoloration was acquired or that an investigation into a possible injury of unknown source was conducted. This was inconsistent with the facility’s Abuse Reporting Policy, which defines injury of unknown source and requires immediate initiation and documentation of a thorough investigation and reporting of any allegation of abuse or injury of unknown source to appropriate authorities within the required timeframe.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the daily nurse staffing information as required, resulting in outdated information being displayed for an extended period. During an observation, it was found that the posted Census and Direct Care Service Hours Per Patient Day (DHPPD) form was dated 19 days prior to the observation date. Interviews with a licensed vocational nurse (LVN) revealed that the infection preventionist (IP) nurse, who was responsible for updating the DHPPD postings, had been on vacation, and the LVN covering the duty forgot to update the daily staffing information. The administrator confirmed that the DHPPD should be posted daily, and a review of the facility's policy indicated that direct care daily staffing numbers are to be posted for every shift.
Wet Food Service Equipment Stored Before Drying
Penalty
Summary
The facility failed to ensure proper drying of cooking and serving equipment when a large baking pan and four steam table pans were found stacked for storage while still wet during an initial kitchen inspection. One large baking pan was observed wet in a stack of baking pans, one steam table pan was observed wet in a stack of steam table pans, and three additional steam table pans were observed wet in another stack of steam table pans. During interview, the dietary manager acknowledged that the one large baking pan and four steam table pans had been stacked for storage while still wet. Review of the facility’s undated Dish Washing policy and procedure stated that dishes are to be air dried in racks before stacking and storing.
Failure to Document Alternatives Before Using Side Rails
Penalty
Summary
The facility failed to ensure that alternatives were attempted and documented before using upper side rails for 32 of 68 sampled residents reviewed for side rail use. During multiple observations on 7/28/25, Residents 1, 4, 6, 12, 16, 17, 18, 25, 26, 31, 32, 33, 43, 48, 50, 51, 56, 59, 70, 82, 83, 84, 86, 87, 88, 89, 93, 94, 95, 96, 100, and 101 were observed with both upper side rails raised. Review of the facility’s Siderails Screening Tool showed the Alternative Measures Tried section was blank for these residents, with no evidence that alternatives were attempted or documented before side rails were used. During interview, the DON stated that on admission the charge nurse asked the resident whether they wanted the side rails up or down, and that side rail use was based on resident preference. The DON also stated that nurses documented alternatives in the Alternative Measures Tried section, but concurrent record review of one resident’s screening tool showed that section was blank, which the DON acknowledged should have been completed. The ADON similarly stated that residents were informed side rails were considered an enabler or used for repositioning, and if residents agreed, they were used. Concurrent review with the ADON confirmed the Alternative Measures Tried section was blank for the 32 residents with side rails. The facility policy, Proper Use of Side rails revised 12/2016, stated documentation would indicate if less restrictive approaches were not successful prior to considering side rails.
Infection Control Failures With Glucometer Disinfection, Catheter Bag Placement, and Hand Hygiene
Penalty
Summary
The facility failed to maintain an infection prevention and control program in three observed situations. During a medication administration observation, an RN performed a blood sugar check on Resident 48 and disinfected a shared glucometer with a Sani-Cloth wipe for only 4 seconds before placing it in a plastic basket. When asked about the contact time, the RN stated it was 5 seconds, but the product label indicated the surface must remain visibly wet for 2 minutes. Another RN later stated she used the same Sani-Cloth wipes for shared glucometers and believed the contact time was 30 seconds, which also did not match the label. The Infection Preventionist confirmed the facility uses Sani-Cloth wipes with a 2-minute contact time and stated staff should know the contact times for disinfectants. During a separate observation in Resident 52's room, a CNA showed the resident's urinary catheter bag positioned behind the wheelchair, covered with a pillowcase, and touching the floor. The CNA later confirmed the bag had been touching the floor after care was provided. In another observation, a CNA assisted a resident to the bathroom while wearing gloves, changed bed linens, removed her gloves without performing hand hygiene, and then handled clean bed linens from the hallway rack and placed them on the resident's bed. The CNA confirmed she did not perform hand hygiene after removing her gloves and before touching the clean linens. The Infection Preventionist and ADON stated staff were expected to perform hand hygiene before and after glove use, and the facility policy identified hand hygiene as the primary means to prevent the spread of infection.
Failure to Protect Resident Privacy and Confidential Clinical Information
Penalty
Summary
The facility failed to maintain a resident's right to privacy and confidentiality when Resident 72's personal information and care instruction were posted on the wall above the head of bed in the resident's room. During observation, an ENT doctor note was seen posted in the room and was visible to roommates and visitors. The note included Resident 72's full name and identified a diagnosis of bilateral hearing loss due to cerumen impaction, along with a request from the resident's daughter for the ENT doctor to examine the resident's ears. During interview, the ADON confirmed that the posted ENT doctor note contained the resident's full name and diagnosis and acknowledged that the resident shares a room with other residents who often have visitors, allowing those visitors the opportunity to view the note. The facility policy titled Dignity stated that confidential clinical information should be protected and that signs indicating a resident's clinical status or care needs should not be openly posted in the resident's room.
Failure to Document Advance Directive Status
Penalty
Summary
The facility failed to document the status of Advance Directives for two residents, Resident 8 and Resident 44. During record review, no Advance Directive was located in either resident’s electronic record, and there was no documentation indicating whether either resident had an Advance Directive. In addition, section D of each resident’s POLST form, which included check boxes for “Advance Directive dated,” “Advance Directive not available,” and “No Advance Directive,” was left blank for both residents. During interviews with the ADON on 7/31/25, she acknowledged that the Advance Directive-related boxes in section D of Resident 8’s POLST and Resident 44’s POLST were not checked and stated that they should have been. The facility’s policy titled Advance Directives, revised December 2016, states that upon admission residents are to be provided written information about the right to refuse or accept treatment and to formulate an Advance Directive, that the Social Services Director or designee is to inquire about the existence of any written Advance Directives, and that information about whether or not the resident has executed an Advance Directive shall be displayed prominently in the medical record.
Unlabeled GT Feeding Formula Bottle
Penalty
Summary
Resident 2 had diagnoses including dysphagia and a gastrostomy tube, and a physician order dated 7/28/25 directed Jevity 1.2 at 70 ml per hour for 12 hours from 9 p.m. to 9 a.m. via feeding pump. During an observation in Resident 2’s room on 7/30/25 at 8:05 a.m., the GT formula bottle was found attached to an enteral feeding pump next to the bed, with a net volume of 1500 ml and the pump showing 792 ml delivered. The bottle was not labeled or dated. During a follow-up observation and interview with RN A on 7/30/25 at 8:10 a.m., RN A confirmed the GT formula bottle was unlabeled and undated and stated it should have been labeled with the resident’s name, the rate of administration, and the date and time the feeding was initiated. The DON later confirmed that GT feeding formula bottles should be labeled with the resident’s name and the date the formula is started, and that the label should indicate the tube feeding order and rate. The facility policy titled Enteral Tube Feeding via Continuous Pump stated that the formula label should document initials, date and time the formula was hung/administered, and initials that the label was checked against the order.
Unlabeled IV Fluids
Penalty
Summary
IV therapy was not properly labeled for one resident receiving 0.45% Sodium Chloride IV fluids. During an observation in the resident’s room, the IV fluid was seen in use without labels showing the resident’s name, the start date and time, medication instructions, or the initials of the nurse who administered it. The resident was receiving IV therapy at the time of the observation. During a concurrent interview, an RN confirmed that the IV fluid lacked the required labels, including the resident’s name, the date and time the IV was initiated, medication instructions or IV rate, and the initials of the administering nurse. The NS later stated that nurses were expected to label IV fluids with the start date and time and the administering nurse’s initials, and noted that the night shift nurse had initiated the IV fluids without labeling or dating them. The MAR showed that Sodium Chloride IV Solution 0.45% for hydration had been administered on the night shift, and the facility policy required additive labels to include the nurse’s initials, date, and time.
Inadequate Monitoring of Antipsychotic and Insulin Side Effects
Penalty
Summary
The facility failed to provide adequate monitoring for three sampled residents whose drug regimens included psychotropic medication or insulin. For one resident with schizophrenia who was receiving risperidone 0.5 mg at bedtime, the medication side effect monitoring did not include tardive dyskinesia or other abnormal motor movements. During interviews and record review, nursing staff and the ADON confirmed that tardive dyskinesia was not included in the antipsychotic side effect monitoring, even though the resident’s care plan specifically identified special attention for tardive dyskinesia and the consultant pharmacist’s medication regimen review noted missing psychotropic monitoring behavior. Two other residents with Type 2 DM were receiving insulin lispro by sliding scale before meals and at bedtime, but their medication orders and MARs did not reflect monitoring for signs and symptoms of hypo/hyperglycemia. During the record review, LVN C, RN A, and the ADON all confirmed that no such monitoring was indicated in the MARs for either resident. RN A stated that signs and symptoms such as confusion and sweating should be included in the monitoring process, and the ADON agreed that these signs and symptoms should be monitored. The records also showed that the facility’s policies addressed monitoring for antipsychotic side effects and diabetes-related complications. The resident with schizophrenia had diagnoses including schizophrenia and was receiving an antipsychotic medication, while the two residents with diabetes had diagnoses of Type 2 DM and were receiving insulin lispro. The deficiency was identified through interview and record review when the monitoring documented in the residents’ records did not match the side effects and symptoms identified in the care plans and facility policies.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure medications and biologicals were appropriately stored and labeled during observation of two medication storage areas. On Station BB, an opened multi-use Lantus insulin pen was found with no date indicating when it had been opened. RN A confirmed the insulin was in use and stated there should have been an open date on the pen. On Station AA, an unopened vial of Procrit was observed in the medication cart even though the label stated to keep the medicine in the refrigerator. LVN C verified that the medication should be refrigerated. During interview, the DON stated medications requiring refrigeration should not be kept in medication carts when the label directs refrigeration, and that insulin pens should be dated when opened and discarded per manufacturer recommendations. The facility policy also stated insulin should be dated and initialed when opened when currently in use.
Improper Quaternary Sanitizer Test Strip Use
Penalty
Summary
The facility failed to ensure proper technique was used when checking the quaternary sanitizer used in the three-compartment sink. During an observation and interview in the kitchen, a Dietary Aide demonstrated how she checked the sanitizer strength by dipping the sanitizer strip for 12.54 seconds, then comparing the reagent square on the dip stick to the results picture on the container. The dip stick read 400 ppm, and the Dietary Aide stated she had held the strip in the sanitizer water for 10 seconds. Review of the instructions on the Insta-Test Analytic sanitized water test strips, QAC 50-400 ppm, showed the directions were to dip and take out, shake off excess water, wait 5 seconds, and compare.
Food Preference Not Followed for Resident
Penalty
Summary
The facility failed to ensure food preferences were honored for one of 17 sampled residents, Resident 90, when she was served zucchini despite it being listed on her meal tray ticket as a dislike. During a meal observation and interview in the resident's room, Resident 90 was seated in a wheelchair with a family friend and eating lunch that included fish, carrots, and zucchini; she stated that she did not like zucchini but it was still served to her. A concurrent review of the meal tray ticket confirmed zucchini was listed in Resident 90's dislikes. During an interview, the Dietary Manager stated the resident's preferences should be followed. The facility policy on Resident Food Preferences states that individual food preferences are to be assessed upon admission, quarterly, and as needed, and that if a resident refuses or is unhappy with the diet, staff will create a care plan that the resident is satisfied with.
Failure to Re-Offer Pneumococcal Vaccines
Penalty
Summary
The facility failed to offer pneumococcal vaccines as required for two sampled residents. Resident 36’s clinical record showed admission on [DATE], and a Pneumococcal Immunization Consent form dated 6/17/24 documented that the resident/family refused the pneumococcal vaccine. During a concurrent interview on 7/31/25 at 4:50 p.m., the DSD/IP confirmed Resident 36 was not offered the pneumococcal vaccine again after admission, and stated that when offering pneumococcal or flu vaccines, staff complete the consent form again or document the offer in the progress notes, but this was not done. Resident 72’s clinical record showed admission on [DATE], and the Pneumococcal Immunization Consent form documented refusal on 6/27/24. During a concurrent interview and record review on 8/1/25 at 11:09 a.m., the DSD/IP acknowledged that Resident 72 was not offered the pneumococcal vaccine again after admission, as required by the facility’s policy, which stated that pneumococcal and influenza vaccines shall be offered and consent obtained on admission and quarterly, if eligible.
Failure to Timely Submit Abuse Investigation Summary
Penalty
Summary
The facility failed to complete and submit an investigation summary regarding an alleged abuse incident that occurred between two residents. On the night of the incident, staff heard yelling and an argument between the two residents, leading to one resident being transferred to another room. The following morning, one resident reported to the DON and Social Services Director that her roommate had tapped her on the back of the head, making her uncomfortable. An assessment was conducted, and no injuries or pain were noted, and the primary physician was notified. Despite the incident being reported to the police, Ombudsman, and the state survey agency, the facility did not provide a written investigation summary to the state agency within the required five working days. The administrator confirmed that there was no fax transmittal confirmation for the five-day summary or investigation summary for the incident, except for a much later fax confirmation. The facility's policy requires prompt reporting and thorough investigation of abuse allegations, with findings reported to appropriate agencies within five working days, which was not followed in this case.
Failure to Complete and Transmit Discharge MDS Assessments
Penalty
Summary
The facility failed to complete and transmit discharge Minimum Data Set (MDS) assessments for two residents, which is a requirement upon their discharge from the facility. Resident #38 was admitted on December 13, 2023, with a medical history including pleural effusion, atrial fibrillation, and peripheral vascular disease. The resident was discharged on February 20, 2024, but there was no evidence of a completed discharge MDS in the medical record. Similarly, Resident #51, admitted on January 3, 2024, with a history of left radius fracture, type two diabetes mellitus, and morbid obesity, was discharged on February 17, 2024, without a completed discharge MDS. Interviews with facility staff revealed that the MDS Coordinator and the Director of Nursing were aware of the requirement to complete and submit discharge MDS assessments within 14 days of a resident's discharge. The MDS Coordinator mentioned that the facility's electronic medical record system generated reports indicating when MDS assessments were due. Despite this, the discharge MDS assessments for both residents were not completed or submitted as required, which was acknowledged by the facility's Administrator, who expected timely submission of MDS assessments by the nursing department.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Los Gatos
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woodlands Healthcare Center | 0.4 mi | ★★★★★ | 2 | 0 |
| Plum Tree Care Center | 0.5 mi | ★★★★★ | 0 | 0 |
| The Terraces Of Los Gatos | 0.9 mi | ★★★★★ | 0 | 0 |
| Childrens Hc Org No Ca -pediatric Hospital D/p Snf | 1 mi | ★★★★★ | 0 | 0 |
| Almaden Health And Rehabilitation Center | 1.1 mi | ★★★★★ | 1 | 0 |
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