Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Stoneybrook Retirement Community during CMS and state inspections, most recent first.
Lack of Required RN Coverage: The facility did not provide RN coverage for 8 consecutive hours per day, 7 days a week. Review of the nursing schedule showed multiple days without the required RN coverage, and staff confirmed the gaps despite having PRN staff available. The facility’s staffing document stated that an RN provides services for at least 8 consecutive hours every 24 hours, 7 days a week.
The facility failed to notify the LTCO when a resident was transferred and admitted to the hospital. The resident’s record documented the hospital admission, but there was no evidence that LTCO notification was completed, and an admin staff member verified she had not notified them. The facility policy required a copy of the discharge notice be sent to an LTCO representative within 30 days.
A resident with COPD, dementia, anxiety, and severe cognitive impairment had no smoking care plan in the EHR despite smoking and requiring staff supervision. Staff were observed providing and lighting the resident's cigarette on the enclosed patio, and the resident then walked back to her room with a walker; the DON verified the resident had designated smoking times and that staff stored her cigarettes, but the smoking assessment and smoking safety details were not documented in a care plan.
Failure to provide scheduled bathing and ADL assistance for two residents. One resident with COPD, dementia, and severe cognitive impairment was supposed to receive showers twice weekly but went 17 days without one and was observed with greasy, uncombed hair and the same clothing. Another resident with dementia, hemiplegia, and anxiety was dependent for all ADLs, yet missed multiple scheduled showers, with long gaps between baths and observations of greasy hair and an unkempt beard; the bathing records did not document refusals.
A resident with anxiety disorder and malnutrition did not consistently receive her ordered Boost Plus with meals and at bedtime. MAR review showed multiple missed doses, and observation found a meal tray served without the supplement while the resident said she had been out of Boost for about a week. Staff stated they were unaware the supply was gone and that tracking and obtaining the supplement depended on communication between med aides, nursing, dietary, and business office staff.
Discontinued insulin was administered to a resident after a nurse saw an order in the EMR’s Supply tab and gave seven units of insulin aspart despite the order having been discontinued. The order was not on the MAR, TAR, or physician orders, and another nurse was unsure where the order had been seen.
A facility failed to properly store and label insulin flex pens when an outdated Humalog pen for a resident was left on the med cart and two Novolog pens for two residents were missing open and discard dates. An LPN and an administrative nurse verified that insulin should be dated when opened and expired pens discarded, and the facility policy required medications to be stored safely and outdated meds removed from stock.
A resident’s blood sugar was checked with a multi-use glucometer, but an LN returned it to the medication cart without disinfecting it and was unsure what disinfectant to use. The same resident’s urinary catheter tubing was repeatedly observed dragging on the carpet and cement floor underneath his wheelchair, and an LN and an administrative nurse confirmed the tubing should not be on the floor.
Essential kitchen equipment was not maintained safely when the ice machine’s top panel was found off the unit with the motor and internal components exposed. Dietary staff said duct tape had been used for a month or two to hold the panel in place because the screw holes were stripped, and Maintenance U said the screws were stripped and needed to be fixed. An admin staff member said maintenance issues were entered into the Tel's system, and a facility maintenance policy was not provided.
A facility failed to provide a resident or their representative with written information about the bed hold policy during a hospital transfer. The resident, who had benign prostatic hyperplasia and an indwelling urinary catheter, was at risk of not being allowed to return to the facility. The facility's policy requires a written notice at the time of transfer, but this was not provided, as confirmed by administrative staff.
A facility failed to assess a resident's ability to smoke safely upon recent admission, despite the resident's complex medical history and behaviors related to smoking rules. The resident's care plan required supervision during smoke breaks, but no current smoking assessment was conducted, contrary to the facility's policy. This placed the resident at risk for injury during smoking.
The facility failed to obtain stop dates for PRN Ativan orders for two residents, contrary to its policy requiring a 14-day limit unless extended by a physician. Resident 30, with multiple diagnoses including anxiety disorder, and Resident 188, with an anxiety disorder, were both prescribed Ativan without specific stop dates, placing them at risk for unnecessary medication use. This deficiency was confirmed by an administrative nurse, indicating a lapse in medication management practices.
Lack of Required RN Coverage
Penalty
Summary
The facility failed to provide RN coverage for eight consecutive hours a day, seven days a week. Review of the nursing schedule showed no consecutive 8-hour RN coverage on multiple dates, including 02/27/26, 02/28/26, 03/01/26, 03/14/26, 03/15/26, 03/29/26, 04/11/26, 04/12/26, 05/09/26, and 05/10/26. On 5/13/26 at 10:15 PM, Administrative Staff A stated that a scheduler prepares the nursing schedule and Administrative Nurse D reviews it, and that PRN staff were available, but they verified that RN coverage was not provided on the listed dates. The facility’s Competent and Sufficient Staffing document stated that a registered nurse provides services for at least eight consecutive hours every 24 hours, seven days a week.
Failure to Notify LTCO of Resident Hospital Transfer
Penalty
Summary
The facility failed to notify the Office of the Long-Term Care Ombudsman when Resident 17 was transferred and admitted to the hospital. The resident’s EMR included a nurse’s note dated 01/11/26 at 04:02 PM documenting that the resident was admitted to the hospital, but the clinical record did not contain evidence that LTCO notification was completed for that transfer. On 05/14/26 at 10:21 AM, Administrative Staff A stated she was responsible for notifying LTCO when Resident 17 was transferred to the hospital and verified that she had not notified them. The facility’s Discharge Criteria Policy, revised 11/28/2017, stated that when a resident was transferred or discharged, staff would send a copy of the discharge notice to a representative of the LTCO within 30 days.
Failure to Care Plan Smoking Safety
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with COPD, dementia, and anxiety to address smoking safety. The resident's admission MDS documented a BIMS score of 3, indicating severe cognitive impairment, and also noted that the resident was independent with ADLs, used a walker for mobility, required staff supervision in the facility, had an elopement alarm used daily, and smoked. The resident's elopement care plan, dated 04/21/26, directed staff to remind the resident the facility is her home when she asks to leave, and the resident had an elopement bracelet that staff were to check for proper function. On 05/12/26 at 04:00 PM, the resident was observed sitting at a table on the enclosed patio, and staff provided the resident with a cigarette and lit it. The resident smoked the cigarette and then independently walked back to her room using a walker. At 03:50 PM that same day, Administrative Nurse D verified the resident smoked and had designated smoking times, and stated the resident would go out with staff supervision and staff would store her cigarettes. Administrative Nurse D also verified the facility lacked a smoking care plan in the resident's electronic health record for staff to view. The facility's smoking policy stated residents would have a smoking assessment completed, residents requiring supervision while smoking may smoke at posted smoking times in designated areas, and smoking materials for supervised residents would be stored and locked at the nurses' station.
Failure to Provide Scheduled Bathing and ADL Assistance
Penalty
Summary
The facility failed to provide necessary ADL services to maintain good personal hygiene, including bathing, for two residents. One resident had COPD, dementia, and anxiety, and an admission MDS documented a BIMS score of 3, indicating severe cognitive impairment. Although the MDS showed the resident required staff supervision for most ADLs, including bathing, the care plan lacked documentation of the needed ADL assistance. The bathing task record showed the resident was scheduled for showers twice weekly, but the resident received only two showers over a 17-day period, and the bathing report did not document any refusal. Observations on multiple dates showed the resident with uncombed, greasy hair while dressed in the same clothing. The second resident had dementia, sleep apnea, hemiplegia, and anxiety, and the MDS documented a BIMS score of 13 and dependence on staff for all ADLs, including bathing, with wheelchair use for mobility. The care plan also lacked documentation of required ADL assistance, including bathing. The bathing task record showed showers were scheduled twice weekly, but the resident received showers on only a few dates, including gaps of 13 days, 16 days, and 38 days between showers, and the bathing report did not document refusal. Observation showed the resident sitting in a wheelchair in street clothes with greasy hair and an unkempt beard and mustache. Administrative staff verified the scheduled shower days, the dates the residents actually received showers, and that the residents did not receive their twice-weekly showers.
Missed ordered nutritional supplement
Penalty
Summary
The facility nursing staff failed to provide adequate nutrition support when Resident 5 did not consistently receive her physician-ordered Boost Plus supplement. Resident 5 had a diagnosis of anxiety disorder, no swallowing disorder, a weight of 134 pounds, and no documented weight loss or gain on her quarterly MDS. Her care plan documented that she could feed herself after her food was set up, was a picky eater, enjoyed milkshakes, and preferred up to five Boost Plus drinks per day as part of her regular meals. A physician order dated 11/14/25 directed staff to provide 240 ml of supplement with meals and at bedtime. Review of the May 2026 MAR showed multiple missed or undocumented Boost administrations, including several breakfast and lunch doses and several evening doses marked as refused. During observation on 05/13/26, LN I brought R5 a meal tray without a Boost drink, and when R5 asked for it, LN I checked the mini refrigerator and found none available. R5 stated she had been out of Boost for about a week and later stated she had not received it with her noon meal. LN I stated R5 only liked cubed potatoes and chocolate shakes and that the facility had to special order the chocolate Boost because the supplier did not carry it. DM BB and Administrative Staff C stated they were unaware R5 was out of Boost and explained that medication aides were responsible for tracking the supply and reporting when it ran out so it could be purchased from a local grocery store. Nurse Consultant GG stated staff were expected to notify nursing when R5 was out of her supplement and follow the physician's orders because she had a diagnosis of malnutrition.
Discontinued insulin was administered
Penalty
Summary
The facility failed to ensure Resident 3 remained free from a significant medication error when a nurse administered seven units of insulin aspart that had been discontinued. During observation, after the nurse checked the resident’s blood sugar, she stated the resident did not need sliding scale insulin but did need noon insulin. She then accessed the facility tablet, primed an insulin FlexPen, and injected seven units into the resident’s abdomen. During record review and interview, the insulin order was not found on the resident’s MAR, TAR, or Physician Orders, and the nurse could not locate an active order on her desktop computer. Another nurse stated she had only given the resident sliding scale insulin at noon and was unsure where the order had been seen. Further review of the EMR located the inactive order under the Supply tab, where it was identified as an order for seven units of insulin aspart that had been discontinued on 09/30/25. The consultant verified the Supply tab was for pharmacy documentation of insulin availability and that the order had not been removed from the EMR, and the nurse should not have administered the seven units.
Improper Storage and Labeling of Insulin Flex Pens
Penalty
Summary
The facility failed to properly store medications when staff did not discard an outdated insulin flex pen for R11 and did not label R3 and R6’s insulin flex pens when they were initially opened for use. During observation of the Rapid Recovery and Purple Pride nurse medication cart, R11’s Humalog flex pen was found labeled with an open date and a discard date that had already passed, while R3 and R6’s Novolog flex pens did not have an open date or discard date documented on them. During interview, the License Nurse verified that insulin should be dated when opened and that outdated insulin flex pens should be discarded. The Administrative Nurse also verified that insulin flex pens should be labeled with the date opened and checked for outdates, with expired pens discarded. The facility’s Storage of Medications policy stated that medications and biologicals are to be stored safely, securely, and properly according to manufacturer recommendations, and that outdated medications are to be removed from stock and disposed of according to procedure.
Failure to Disinfect Shared Glucometer and Keep Catheter Tubing Off the Floor
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when staff did not disinfect a multi-use glucometer after using it to obtain a blood sugar reading for R3. During observation, LN G checked R3’s blood sugar with the glucometer and then placed it back into the bag and onto the medication cart without disinfecting it. LN G verified that the device was a multi-use glucometer and stated she thought the night shift may have been responsible for disinfecting it, and she was not sure what should be used to disinfect it. A nurse consultant later stated that all residents should have their own glucometer and that LN G should have disinfected the glucometer with a Sani-wipe before putting it away. The facility also failed to keep R3’s urinary catheter tubing from dragging on the floor underneath his wheelchair. On observation, R3 was seen sitting in a wheelchair in the dining room with the catheter tubing underneath the wheelchair seat and touching the floor carpet, and later propelled himself out the patio exit door with the tubing dragging on the carpeted floor and the patio cement floor. A later observation again showed the tubing underneath the wheelchair seat and touching the carpet floor. LN H verified that the tubing was touching the carpeted floor and stated it should not be. An administrative nurse stated that staff should position R3’s urinary catheter tubing under his wheelchair, off the floor. The facility did not provide a urinary catheter policy regarding placement of catheter tubing or cleaning of shared equipment.
Ice Machine Panel Not Secured
Penalty
Summary
Essential kitchen equipment was not maintained in a safe operating condition when the ice machine’s top panel was found lying on top of the machine with the motor and internal components exposed. During observation, Dietary BB stated that duct tape was being used to hold the panel in place because the screw holes were stripped and that it had been that way for a month or two. Maintenance U later stated that the screws were stripped, that he needed to fix them, and that staff had been holding the panel in place for a couple of months while he looked for the right screws. Dietary CC stated that she had to remove the top panel monthly to clean the ice machine and that the screw holes were stripped, so the panel was held on with duct tape. Administrative Staff A stated that equipment needing maintenance was entered into the Tel's system for Maintenance U to fix, and also stated that the panel was usually in place but had come loose when the duct tape did not hold it. A facility maintenance policy was not provided upon request.
Failure to Provide Bed Hold Policy to Resident During Hospital Transfer
Penalty
Summary
The facility failed to provide Resident 13 or his representative with written information regarding the facility's bed hold policy when the resident was transferred to the hospital. This deficiency was identified during a review of the resident's clinical record, which lacked evidence of the bed hold policy being provided at the time of transfer. The facility's bed hold policy, revised in 2017, mandates that a written notice specifying the duration of the bed hold be given at the time of a resident's transfer for hospitalization or therapeutic leave. However, Administrative Staff A confirmed that the resident had not received this information upon transfer. Resident 13 had a diagnosis of benign prostatic hyperplasia and was at risk for urinary tract infections due to an indwelling urinary catheter. The resident's care plan included specific instructions for catheter care to prevent complications. Despite these medical needs, the facility's oversight in not providing the bed hold policy placed the resident at risk of not being permitted to return and resume residence in the nursing facility. Observations noted the resident in a wheelchair with clear urine in the catheter tubing, indicating ongoing management of the resident's condition.
Failure to Assess Resident's Smoking Ability
Penalty
Summary
The facility failed to assess Resident 10's ability to smoke safely, which placed the resident at risk for injury during smoking. Resident 10 had a complex medical history, including chronic obstructive pulmonary disease, peripheral vascular disease, congestive heart failure, a right femur fracture, dementia, major depressive disorder, and a personal history of nicotine and alcohol dependence. Despite these conditions, the facility did not conduct a current smoking assessment upon the resident's recent admission, relying instead on an outdated assessment from a previous admission. Observations and interviews revealed that Resident 10 exhibited behaviors such as verbal outbursts, rejection of care, and agitation regarding smoking rules. The resident's care plan indicated that smoking supplies were kept locked, and the resident was allowed to smoke with supervision during designated smoke breaks. However, the resident often became upset about the smoking schedule and rules, and there were instances where the resident extended smoking times beyond the set limits. Staff were required to remind the resident of the smoking time frames and were present during smoking sessions. The facility's smoking policy required a smoking assessment to be completed for residents who expressed a desire to smoke, with reassessments conducted quarterly or upon significant changes in the resident's condition. Despite this policy, the facility did not complete a smoking assessment for Resident 10 upon their recent admission, as confirmed by an administrative nurse. This oversight in following the facility's smoking policy contributed to the deficiency identified by the surveyors.
Failure to Obtain Stop Dates for PRN Ativan Orders
Penalty
Summary
The facility failed to obtain a stop date from the physician for the continued use of Ativan, an antianxiety medication, as needed (PRN) for two residents, placing them at risk for complications related to unnecessary psychotropic medications. Resident 30, who had diagnoses including generalized anxiety disorder, convulsions, sleep apnea, obsessive-compulsive disorder, and insomnia, was prescribed Ativan PRN for anxiety without a specific stop date. The care plan for Resident 30 indicated that the resident often became anxious, leading to behaviors such as fast-talking and restlessness, and directed staff to administer Ativan if needed. However, the physician's order for Ativan was indefinite, lacking a required stop date. Similarly, Resident 188, diagnosed with an anxiety disorder, was also prescribed Ativan PRN for anxiety without an end date. The care plan for Resident 188 instructed staff to monitor for reactions to medications with black box warnings and to leave the resident alone when angry or agitated. Despite these instructions, the physician's order for Ativan did not include a stop date, contrary to the facility's policy that PRN orders for psychoactive medications should be limited to 14 days unless extended by the physician with documented rationale. The facility's failure to adhere to its Psychoactive Medication policy, which mandates a 14-day limit on PRN orders for antianxiety medications unless extended with proper documentation, resulted in the absence of stop dates for Ativan prescriptions for both residents. This oversight was confirmed by Administrative Nurse D, who acknowledged the lack of stop dates for the PRN Ativan orders for both residents, highlighting a deficiency in the facility's medication management practices.
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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 Manhattan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Via Christi Village Manhattan, Inc | 1.4 mi | ★★★★★ | 8 | 1 |
| Meadowlark Hills | 2.9 mi | ★★★★★ | 0 | 0 |
| Leonardville Nursing Home | 16.6 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society - Valley Vista | 16.7 mi | ★★★★★ | 0 | 0 |
| Westy Community Care Home | 16.8 mi | ★★★★★ | 0 | 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.