Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Post Acute during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, hemiparesis, and total dependence for toileting and bed mobility was care planned for two-person assistance, low bed position, and floor mats on both sides of the bed. During incontinence care, a CNA elevated the bed, turned the resident to assess for soiling, then left the room to obtain supplies and assistance, leaving the resident alone with the bed not fully lowered and with uncertainty about floor mat use. The resident fell from the bed to the floor and was later found with facial bruising, abrasions, and right leg deformity; hospital evaluation identified a frontal/perinasal hematoma and a comminuted distal femur fracture. The DON stated the CNA should not have left the dependent resident alone with the bed elevated and that required fall-prevention measures, including floor mats and two-person assist, were not in place at the time of the incident.
A resident with documented capacity and an active DNR order did not have a completed POLST form on file. During a medical emergency, staff initiated CPR and emergency responders used a defibrillator, despite the DNR order. The facility's policy required honoring DNR orders and completing state-specific forms, but these were not followed, resulting in unwanted resuscitative interventions.
A resident reported that a CNA was rough during care, resulting in pain and difficulty urinating. Although the incident was reported to authorities and the CNA was suspended, the facility failed to retain or provide the investigation summary and could not confirm if the required report was sent to the State Agency. The investigation documents were missing following a change in facility ownership, and the relevant policy for reporting was not available.
Three resident rooms were found to have privacy curtains that were worn, frayed, and torn, with loose threads and exposed linings, detracting from the homelike appearance of the rooms. The Housekeeping Supervisor confirmed the lack of a routine inspection schedule for curtains and acknowledged that many rooms required curtain replacement, but no new curtains had been ordered.
The facility did not ensure accurate MDS assessments for three residents. One resident's code status was incorrectly recorded, another's issues with ill-fitting dentures were not reflected in the MDS despite documentation and resident report, and a third resident's discharge location was inaccurately documented. Staff interviews confirmed these errors and a lack of familiarity with the MDS process.
A resident with a history of bipolar disorder was diagnosed with major depressive disorder with psychotic symptoms, but the facility did not refer the resident for a required Level II PASARR evaluation as outlined in facility policy. Staff interviews revealed a lack of awareness about the need for a new PASARR screening following a new mental illness diagnosis, resulting in the deficiency.
Two residents with severe cognitive impairment and significant physical limitations were observed using bed rails or bed canes without the required assessments being completed. Staff interviews confirmed that the facility did not follow its policy to evaluate residents for bed rail use, resulting in the use of these devices without proper assessment or documentation.
A resident with moderate cognitive impairment and a history of chronic kidney disease experienced ongoing issues with ill-fitting dentures. Despite a dentist's recommendation for new dentures and a denial of coverage by state insurance, the DSS did not provide timely or documented follow-up to assist the resident in obtaining needed dental care or alternative solutions. Staff interviews confirmed the lack of follow-up and absence of a dental care policy.
Staff did not follow enhanced barrier precautions or perform required hand hygiene during care for two residents with invasive devices and wounds, and failed to properly store respiratory equipment for another resident. Gowns were not worn during high-contact care, hand hygiene was omitted between glove changes, and CPAP/nebulizer masks were left out instead of being bagged, contrary to facility expectations and policies.
A resident with intact cognitive status alleged that a CNA bumped his foot into a wall while being pushed in a wheelchair. Despite the complaint being reported to the DON, no thorough investigation was conducted, and the grievance was not documented or resolved according to the facility's policy. The incident was observed by an OT, who noted the wheelchair's footrest hitting the wall, but the resident's foot was not seen making contact. The failure to address the grievance could have caused emotional distress to the resident.
A medication administration error occurred when an LVN in a long-term care facility mistakenly provided Bengay cream instead of a prescribed skin barrier cream to a CNA for application on a resident with severe cognitive impairment. This resulted in the resident experiencing pain and a burning sensation. The facility's policy requiring licensed nurses to administer medications as ordered was not followed.
A resident developed Moisture-Associated Skin Damage (MASD) and a Stage 3 pressure injury due to the facility's failure to initiate and implement appropriate care plans. Despite being at high risk for pressure injuries, the resident did not receive necessary interventions such as turning, repositioning, and the use of a low air-loss mattress. The facility also did not create care plans for the MASD and Stage 3 pressure injury, as confirmed by the Wound Nurse (WN) and Director of Nursing (DON).
The facility failed to meet professional standards of care for a resident by not weighing the resident per physician's orders, not mobilizing the resident out of bed as ordered, and not implementing care plans for the resident's worsening wound. The resident developed a Stage 3 pressure injury, and there was no oversight of the wound's progression.
Failure to Provide Safe, Supervised Incontinence Care Resulting in Fall and Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from accident hazards and received adequate supervision during incontinence care, resulting in a fall from bed and multiple injuries. The resident was admitted in December 2025 and had a Minimum Data Set (MDS) dated 12/17/25 showing a Brief Interview for Mental Status (BIMS) score of 3/15, indicating severely impaired cognition. The MDS Section GG documented that the resident was dependent for toileting hygiene. The baseline care plan dated 12/12/25 specified that the resident required two-person physical assistance for personal hygiene and bed mobility. A fall risk care plan initiated on 12/12/25 included interventions such as floor mats on both sides of the bed, keeping the bed in a low position, and frequent monitoring when the resident was in bed or a chair, with a goal of no falls over a 90-day period. Skilled charting dated 12/31/25 documented that the resident did not bear weight, had an unsteady gait requiring supervision, impaired balance, weakness, and paralysis, and required assistance with transfers and toilet use. The resident was incontinent of urine. On 1/2/26, a change of condition note indicated the resident had fallen out of bed, with impaired balance identified as a fall risk factor. A post-fall evaluation on 1/2/26 recorded that the fall occurred at noon in the resident’s room, with poor balance noted as a factor. The incident summary described the resident, a 77-year-old female with hemiplegia and hemiparesis following a cerebral infarction affecting the left dominant side, as confused but able to move herself toward her left side and fall from the bed to the floor. The resident sustained a skin tear on the forehead and right facial area below the periorbital region and complained of left arm pain rated 6/10, and was transported to a hospital for evaluation. A rehab post-fall review dated 1/8/26 stated that the event occurred in the resident’s bedroom from the bed and that a CNA had begun to change the resident, then left the room to obtain supplies and assistance while the bed was at working height and not lowered. The air mattress was described as having adjusted and slid the resident out of bed, and the resident was found on the floor when the CNA returned. In an interview, the CNA reported being informed by the family that the resident needed incontinence care, entering the room alone to confirm incontinence and obtain consent for a shower, elevating the bed, and turning the resident to assess the brief, confirming stool incontinence. The CNA stated the bed was lowered “a little” before leaving the room to gather gloves and request assistance, and that moments later the resident was found on the floor; the CNA was unsure if floor mats were in place. The CNA acknowledged knowing the resident required two-person assistance for incontinence care but wanted to confirm soiling and consent first, and stated that two-person assistance was important so dependent residents were not left alone. During a concurrent interview and record review with the ADON and DON, the fall care plan and rehab post-fall review were examined. The DON stated that, based on documentation listing floor mats as a post-fall intervention, it could be assumed there were no floor mats in place at the time of the fall. The DON further stated that the CNA should not have left the resident with side rails down and the bed elevated before exiting the room, and should have gathered necessary supplies and requested assistance before entering the room for incontinence care. The DON explained that due to the resident’s limited cognition and one-sided partial mobility, the resident was able to shift herself off the bed onto the floor, and that dependent, total-care residents warranted two-person assistance for incontinence care and should not be left alone mid-care. Hospital emergency department documentation described the fall as unwitnessed, with the resident found on the floor about 15 minutes after last being seen, and noted lacerations and abrasions, shortening of the right leg, and a reported “pop” in the right lower extremity. Imaging showed a frontal/perinasal hematoma and a comminuted distal right femoral fracture. Facility policies on falls and resident quality of care required identification of fall risk factors, implementation of interventions to prevent falls, and provision of a safe environment free of accident hazards with adequate supervision.
Failure to Honor DNR Order and Complete POLST During Medical Emergency
Penalty
Summary
The facility failed to ensure that a Physician's Orders for Life Sustaining Treatment (POLST) was completed and that an existing Do Not Resuscitate (DNR) physician order was followed for one resident during a medical emergency. The resident, who was self-responsible and had documented capacity to make medical decisions, had an active DNR order in place. During a medical emergency, the resident was found unresponsive, with no vital signs, and CPR was initiated by a registered nurse. Emergency responders arrived and used a defibrillator, successfully obtaining a pulse before suspending CPR. The emergency team was informed of the DNR order but noted that no POLST was on file, and the facility was asked to contact the family to clarify the code status. Record review and staff interviews confirmed that although the resident had a DNR order, there was no completed POLST form in the resident's file. The facility's policy required that DNR orders be honored and specified that no resuscitative measures should be used when such orders are in effect. Despite this, CPR and defibrillation were performed. Documentation showed that the resident's wishes regarding resuscitation had been discussed and verbally consented to, but the required POLST form was not completed or available at the time of the emergency.
Failure to Timely Report and Retain Abuse Investigation Results
Penalty
Summary
The facility failed to ensure that the results of an investigation into an abuse allegation were reported in a timely manner to the State Agency, as required. A resident, who had no cognitive impairment, reported to social services that a CNA was rough with him during care, causing pain and subsequent difficulty urinating. The incident was reported to the appropriate authorities, and the CNA was suspended and reassigned. However, when surveyors requested the investigation summary, the current Director of Nursing and Administrator were unable to locate the investigation documents, stating that the facility had transitioned to a new company and the records were left by the previous administration. Interviews with former administrative staff confirmed that the investigation was conducted and the abuse allegation was reported, but the specific investigation notes and summary could not be found. The current administration searched for the documents without success and could not confirm if the required 5-day investigation report was sent to the State Agency. The facility's policy required the use of an abuse investigation process as mandated by law, but the relevant policy and procedure for reporting investigation notes or summaries was not available in the provided documentation.
Failure to Maintain Homelike Environment Due to Worn Privacy Curtains
Penalty
Summary
The facility failed to maintain a homelike environment for residents when three out of four sampled rooms were observed to have privacy curtains that were worn and frayed along the bottom and side edges, detracting from the appearance of the resident rooms. During observation and interview, the Housekeeping Supervisor confirmed that the curtains in these rooms were torn, with loose threads and exposed linings, and acknowledged that there was no routine schedule for inspecting the condition of privacy curtains; inspections were only conducted on an as-needed basis. A review of purchase orders revealed that no new privacy curtains had been ordered, despite the Housekeeping Supervisor's belief to the contrary. Further, it was stated that 28 out of 69 resident rooms required replacement of privacy curtains. The facility's policy indicated that residents are to be provided with a safe, clean, comfortable, and homelike environment.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for three residents. For one resident with a history of spinal stenosis, COPD, dementia, and major depressive disorder, the MDS indicated a code status of CPR, while the resident's active orders reflected a DNR status. The MDS nurse responsible for the assessment was unavailable for interview, and both the Director of Nursing and the Administrator stated they were unfamiliar with the MDS process but expected accuracy. Another resident with hypertensive chronic kidney disease had ill-fitting dentures documented in dental and social services records, and the resident reported issues with denture fit. However, the MDS did not reflect the presence of broken or loosely fitting dentures. The MDS nurse acknowledged the oversight. In a third case, a resident who was discharged home was incorrectly documented in the MDS as having been discharged to a hospital. The MDS nurse admitted to the error, and both the DON and Administrator confirmed the MDS should accurately reflect the discharge location.
Failure to Refer Resident for Level II PASARR Evaluation After New Mental Illness Diagnosis
Penalty
Summary
The facility failed to refer a resident for a Level II Pre-Admission Screening and Resident Review (PASARR) evaluation after the resident was identified with a new diagnosis of major depressive disorder with psychotic symptoms. The resident, who had a history of bipolar disorder and was admitted to the facility several years prior, received the new diagnosis, which was documented in the medical record. The facility's policy required referral for a Level II PASARR evaluation upon identification of a new or possible serious mental disorder, but there was no evidence in the resident's record that such a referral was made following the new diagnosis. The resident's care plan and medication orders reflected the new diagnosis, including the administration of antidepressant medication. Interviews with facility staff revealed a lack of awareness regarding the need for a new PASARR screening when a resident receives a new mental illness diagnosis. The receptionist, responsible for the PASARR process, was unaware of the requirement, and the administrator confirmed that a new PASARR should be completed in such cases. This failure to coordinate and refer for the required PASARR evaluation constituted the deficiency.
Failure to Assess Residents for Bed Rail Use
Penalty
Summary
The facility failed to assess two residents for the use of bed rails, as required by their policy and regulatory standards. Both residents had significant medical histories and severe cognitive impairment, requiring substantial or maximal assistance with bed mobility and transfers. Despite these needs, there was no documented assessment for the use of bed rails for either resident, and both were observed with bed rails or bed canes in use during the survey. For the first resident, who had a history of polymyalgia rheumatica and falls, and was totally dependent on staff for activities of daily living, quarter rails were observed in the up position on both sides of the bed. Interviews with facility staff, including the Administrator, Director of Rehabilitation, and DON, confirmed that no assessment had been completed for the use of bed rails for this resident. The facility's policy required an assessment at admission, readmission, quarterly, and with changes in condition, but this was not followed. The second resident, with hemiplegia, hemiparesis, and epilepsy, also had severe cognitive impairment and required total assistance from two staff for bed mobility and transfers. This resident was observed with bed canes (rails) on both sides of the bed and was unable to communicate their use. Staff interviews revealed that therapy was responsible for assessments, but no evaluation had been completed. Multiple staff, including the Administrator, DOR, and DON, acknowledged the lack of required assessments and indicated a breakdown in the facility's system for ensuring proper evaluation before bed rail use.
Failure to Provide Timely Social Services Follow-Up for Dental Care
Penalty
Summary
The facility failed to provide timely follow-up of medically related social services to assist a resident in obtaining dental services for the replacement of ill-fitting dentures. The resident, who had a history of hypertensive chronic kidney disease and moderate cognitive impairment, was identified as having ill-fitting upper and lower dentures during a dental evaluation. Despite the dentist's recommendation for new dentures and subsequent denial of coverage by the state insurance, there was a lack of documented follow-up by the Director of Social Services (DSS) to assist the resident in finding alternative dental care or resolving the coverage issue. The resident repeatedly expressed concerns about the unresolved denture situation, and the DSS acknowledged being aware of the problem but did not document any follow-up actions or communication with the resident regarding the denial or next steps. Interviews with facility staff, including the DSS, dental hygienist, dental office manager, and administrator, confirmed that the resident's need for new dentures was known, the insurance denial was communicated to the DSS, and there was an expectation for follow-up that did not occur. The DSS also stated there was no dental care policy or procedure in place at the facility. The lack of timely and documented follow-up resulted in the resident continuing to experience issues with ill-fitting dentures, impacting their ability to wear them.
Failure to Implement Infection Control Precautions and Proper Equipment Storage
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) and proper infection control measures for multiple residents. For one resident with a gastrostomy tube and severe cognitive impairment, staff did not wear gowns during high-contact care activities such as incontinence care and gastrostomy tube dressing changes, despite facility policy requiring gown and glove use for residents with invasive devices. Additionally, during a gastrostomy tube dressing change, a nurse changed gloves without performing hand hygiene, contrary to facility policy and staff knowledge. Another resident with a deep tissue pressure injury and moderate cognitive impairment received wound care from a nurse who failed to perform hand hygiene after removing gloves and before donning new gloves. The nurse acknowledged the lapse, and both the DON and Administrator confirmed that hand hygiene should occur before and after glove changes, as well as between glove changes, in accordance with facility policy. The facility also did not ensure proper storage of respiratory equipment for a resident using a CPAP and nebulizer. Observations revealed that the CPAP and nebulizer masks were left out in the open and not stored in bags when not in use, as required to prevent infection. Staff interviews confirmed the expectation that such equipment should be stored in bags, but the facility lacked a written policy on respiratory equipment storage. The Administrator was unaware of the procedure but agreed that masks should be cleaned and stored in bags after use if that was the expectation.
Failure to Address Resident Grievance
Penalty
Summary
The facility failed to address and resolve a grievance made by a resident, identified as Resident 1, who alleged that a Certified Nursing Assistant (CNA1) dragged and bumped his right foot into a wall while being pushed in a wheelchair. The incident was reported to the Director of Nursing (DON) by the resident's daughter, who is also the responsible party. Despite the complaint, the DON did not conduct a thorough investigation or interview witnesses, as he believed CNA1's account that the resident's foot did not hit the wall due to the presence of a footrest on the wheelchair. Resident 1, who had a BIMS score of 15 indicating intact cognitive status, was able to clearly express his concerns. The resident had limitations in the range of motion in the lower extremity and was diagnosed with heart failure and muscle wasting. The Occupational Therapist (OT) observed the wheelchair's footrest bumping into the wall but did not see the resident's actual foot make contact. Despite this, the resident complained that his foot was hit, and the incident was discussed in a daily stand-up meeting. The facility's grievance policy, which mandates prompt and fair resolution of complaints, was not followed. The DON admitted to not documenting the complaint in the resident's medical records and failing to follow up with the resident or the responsible party. This oversight had the potential to cause emotional distress to the resident, as the grievance was not addressed in a timely or thorough manner.
Medication Administration Error Leads to Resident Discomfort
Penalty
Summary
The facility failed to ensure that a licensed vocational nurse (LVN) administered medication accurately and safely to a resident, resulting in pain and discomfort. The incident involved the administration of Bengay cream, which is used for treating minor aches and pains, instead of a prescribed skin barrier cream for moisture-associated skin damage. This error occurred when the LVN handed the wrong cream to a certified nursing assistant (CNA) to apply on the resident's skin during a change. The resident, who had severe cognitive impairment and was diagnosed with conditions including dementia and osteoarthritis, experienced a burning sensation in the affected area due to the application of the incorrect cream. The error was confirmed by the LVN during an interview, where it was revealed that the Bengay cream was mistakenly given instead of the Coloplast Critic-Aid barrier cream. The facility's policy and procedure for medication administration, which requires medications to be administered by licensed nurses as ordered by the resident's physician, was not followed. The medication error was documented in a report, indicating that the Bengay cream was applied instead of the barrier cream, causing the resident pain and a burning sensation.
Failure to Implement Care Plans for Skin Damage and Pressure Injuries
Penalty
Summary
The facility failed to initiate and implement person-centered care plans for a resident who developed Moisture-Associated Skin Damage (MASD) and a Stage 3 pressure injury. The resident, who was admitted with multiple diagnoses including rheumatic tricuspid insufficiency, chronic heart failure, and pulmonary hypertension, was identified as being at high risk for pressure injuries based on a Braden Scale score of 11. Despite this, the facility did not create a care plan for the MASD that was discovered on the resident's sacrococcygeal area, as confirmed by the Wound Nurse (WN) during an interview and record review. The facility also failed to implement necessary interventions to prevent the resident from developing a pressure injury. The resident's care plan included instructions for turning and repositioning every two hours and the use of a pressure-relieving mattress, but these interventions were not followed. The resident was documented as staying in bed without being turned or repositioned 178 times between July and October. Additionally, the resident did not have a low air-loss (LAL) mattress, which was only ordered upon discharge. The Director of Nursing (DON) confirmed these lapses during an interview and record review. Furthermore, the facility did not initiate a care plan when the resident developed a Stage 3 pressure injury on the sacrococcygeal region. Progress notes indicated the presence of an open wound that progressed to a Stage 3 injury, but no care plan was created to address this condition. Both the WN and the DON confirmed the absence of a care plan for the Stage 3 pressure injury during interviews. The facility's policies on the prevention and treatment of pressure injuries were not followed, as care plans were not initiated for each skin concern as required.
Failure to Meet Professional Standards of Care
Penalty
Summary
The facility failed to ensure care provided met professional standards of care for one resident when nursing staff did not weigh the resident per physician's orders. The resident had multiple physician orders for weekly weights on specific days, but the records indicated that the resident was not weighed on numerous occasions as ordered. The Director of Nursing (DON) confirmed that the resident was not weighed according to the physician's orders during a telephone interview and record review. Additionally, the nursing staff did not get the resident out of bed as ordered by the physician. The resident's care plan and physician's orders indicated that the resident should be out of bed to a chair for meals every shift and up in a wheelchair for at least four hours a day. However, progress notes showed that the resident stayed in bed for extended periods, and there was no documented evidence that the resident was mobilized out of bed for meals. The DON confirmed that the nursing progress notes did not indicate the resident was mobilized out of bed as expected. Furthermore, the facility failed to implement or initiate care plans as the resident's wound continued to worsen. The resident developed a facility-acquired Stage 3 pressure injury on the sacrococcygeal region. Despite having a care plan for potential skin breakdown, there was no care plan initiated for the resident's Moisture-Associated Skin Damage (MASD) or the subsequent Stage 3 pressure injury. The Wound Nurse (WN) and DON confirmed that there was no care plan for the resident's MASD or Stage 3 wound, and the resident did not have a low air-loss mattress as required. The facility also lacked oversight of the resident's worsening wound, with no additional Braden Scale assessments documented after a certain date, and no specialized wound consultant overseeing the WN's work.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
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Nursing homes near Concord
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Diablo Valley Post Acute | 1.7 mi | ★★★★★ | 15 | 0 |
| Willow Pass Healthcare Center | 2.2 mi | ★★★★★ | 6 | 0 |
| Concord Post Acute | 3 mi | ★★★★★ | 5 | 0 |
| Bayberry Skilled Nursing & Healthcare Center | 3.3 mi | ★★★★★ | 16 | 0 |
| Shadelands Post Acute | 3.8 mi | ★★★★★ | 20 | 0 |
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