Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around September 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 Stonehaven Senior Living during CMS and state inspections, most recent first.
Surveyors observed unsanitary conditions in the kitchen, including discoloration on the underside of the ice machine and food crumbs with utensils under storage racks in the dry food storage room. The RD, CDM, MD, and DON confirmed the presence of these issues, and cleaning logs did not reflect adequate maintenance. Facility policies and job descriptions required cleanliness, but these standards were not met.
A brown sludge-like residue was found on the laundry room floor, measuring about six inches wide and thirty inches long, due to water accumulation and lack of regular cleaning. Staff interviews confirmed the buildup was not reported or addressed, and both the DON and infection preventionist identified the unsanitary condition as an infection control concern, with facility policy requiring daily cleaning of laundry areas.
The facility did not maintain its walk-in freezer in safe operating condition, as evidenced by persistent ice buildup in multiple areas, lack of maintenance documentation, and delayed repairs despite repeated observations and audits by dietary and infection prevention staff.
A medication vial of Ipratropium bromide and albuterol sulfate, prescribed for a resident with COPD, was found stored outside its manufacturer foil packaging in the med cart. An LVN confirmed this was improper storage, and the DON stated that such storage could decrease the medication's potency. Manufacturer guidelines and facility policy both require the medication to be kept in its original packaging until use.
Two residents did not receive meals in accordance with their documented preferences and dietary instructions. One resident was not served a preferred chocolate ice cream dessert, while another received a dessert despite a clear instruction to avoid sweets. Staff interviews and documentation confirmed that meal tickets and resident preferences were not properly followed, contrary to facility policy and job descriptions.
Unsanitary Kitchen Conditions: Ice Machine Discoloration and Food Debris in Storage
Penalty
Summary
A deficiency was identified in the facility's kitchen related to unsanitary conditions. During observations, surveyors noted pink and blue discoloration on the underside of the ice machine's back panel, which was confirmed by the registered dietician (RD), certified dietary manager (CDM), maintenance director (MD), and director of nursing (DON). The facility's cleaning logs indicated the ice machine had been deep cleaned and sanitized in the months prior, but the discoloration remained present. Manufacturer guidelines for the ice machine require regular cleaning and sanitizing, and all interviewed staff acknowledged the importance of maintaining a clean ice machine to prevent contamination. Additionally, the dry food storage room was found to have food crumbs and spoons under storage racks, as confirmed by the RD and CDM. The CDM reported that the floor was only swept once a week and there were no cleaning logs for the dry food storage room. The presence of food remnants was acknowledged by the cook and DON, both of whom stated that such conditions could attract pests and compromise sanitation. Facility policies and job descriptions reviewed by surveyors required that kitchen and storage areas be kept clean and sanitary, but these standards were not met at the time of the survey.
Failure to Maintain Sanitary Laundry Room Environment
Penalty
Summary
The facility failed to maintain the laundry room in a clean and sanitary condition for all eight sampled residents, as evidenced by the presence of a brown sludge-like residue on the floor next to the washing machine. Observations revealed that the sludge measured approximately six inches wide and thirty inches long, and had accumulated due to water pooling over time. The laundry worker acknowledged that the floor had not been cleaned regularly, which led to the buildup and made it difficult to fully clean and sanitize the area. The maintenance supervisor confirmed the presence of the sludge and stated that staff should have reported the condition, noting that the buildup could have resulted from a washer leak and could affect the cleanliness of the laundry and clothing. Further interviews with the DON and the infection preventionist confirmed that the laundry room should have been kept clean and that the dirty floor was an infection control concern. The infection preventionist specifically stated that laundry staff should have reported the brown sludge, as the unsanitary condition could cross-contaminate clothing washed in the machine. A review of the facility's policy indicated that floors, surfaces, and equipment in the laundry area must be cleaned daily to maintain a sanitary environment, which was not followed in this instance.
Failure to Maintain Walk-In Freezer in Safe Operating Condition
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition, specifically the walk-in freezer in the kitchen, which was observed to have significant ice buildup in several areas. During multiple observations and interviews, ice accumulation was noted on the door frame, an electrical box, a shelving rack, a laminated storage chart, and a thermometer. The registered dietician and certified dietary manager both confirmed the presence of ice buildup, and the issue was documented in monthly audits as not being met. The ice buildup was first noticed by the certified dietary manager in February, and subsequent audits in February and April continued to note the deficiency. Despite the ongoing issue, there was a lack of maintenance logs or documentation regarding troubleshooting efforts by facility staff. The facility engaged a third-party vendor to service the freezer, including replacing a valve cord and compressor, and conducting diagnostics, but there was no written record of the diagnostic findings or recommendations. A second vendor was later consulted, but no repairs were made between vendor visits, and the ice buildup persisted. Parts needed for repair were not ordered until after the state surveyor's inspection, and there was no documentation of discussions or decisions made regarding the delay in repairs. Interviews with the maintenance director revealed that some attempts were made to address the issue, such as replacing the door gasket and latch, but these actions were not documented, and the director could not recall when the work was performed. The infection preventionist's audit only checked the temperature log and did not inspect the freezer for ice buildup. Job descriptions for the culinary director and registered dietician indicated responsibility for maintaining documentation and compliance with food storage requirements, but the ongoing ice buildup and lack of documentation demonstrated a failure to meet these standards.
Improper Storage of Inhalation Medication Vial
Penalty
Summary
A deficiency occurred when a medication vial of Ipratropium bromide and albuterol sulfate, prescribed for a resident with chronic obstructive pulmonary disease (COPD), was found stored outside of its manufacturer-provided foil packaging in the medication storage cart. During observation and interview, a Licensed Vocational Nurse (LVN) confirmed that the medication should have remained in its original packaging, as storing it outside could reduce its duration and effectiveness. The resident's records indicated a diagnosis of COPD and a physician's order for the medication to be administered every eight hours via nebulizer. Further interviews with the Director of Nursing (DON) revealed that staff were expected to inspect the medication cart daily to ensure proper storage of all medications. The DON acknowledged that storing the medication outside of the foil packaging could shorten its shelf life and decrease its potency, which is particularly significant for a resident requiring regular breathing treatments. Review of manufacturer guidelines and facility policy confirmed that the medication should be protected from light and kept in its original container until use.
Failure to Follow Resident Meal Preferences and Dietary Instructions
Penalty
Summary
The facility failed to provide meals in accordance with resident preferences and dietary instructions for two residents. In one instance, a resident did not receive a chocolate ice cream dessert as listed on her meal ticket, despite her stated preference and the expectation that her meal would include this item. Observations and interviews with staff confirmed that the resident's preference was documented and should have been honored, but the item was omitted from her tray. The Certified Dietary Manager (CDM) and Director of Nursing (DON) both acknowledged that the resident should have received her preferred dessert and that staff are expected to check trays for accuracy before serving. In another case, a resident with moderate cognitive impairment was served a dessert despite a clear instruction on the meal ticket to not serve sweets or desserts. The resident's meal ticket, dietary records, and staff interviews confirmed that the dessert was not appropriate for this resident. The CDM and DON both stated that the resident's dietary preferences and restrictions should have been followed to ensure person-centered care and nutritional needs were met. Facility policies and job descriptions reviewed also indicated that staff are required to check meal tickets for allergies, preferences, and specific instructions before serving meals.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Twilight Haven | 0 mi | — | 0 | 0 |
| Pacific Gardens Nursing And Rehabilitation Center | 0.9 mi | ★★★★★ | 30 | 0 |
| Evergreen Care Center | 1 mi | ★★★★★ | 2 | 0 |
| Sierra Vista Healthcare | 1.1 mi | ★★★★★ | 18 | 0 |
| Orchard Post Acute | 1.1 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.