Average — CMS composite of the measures below.
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 Stonebridge At Montgomery Health Care Center during CMS and state inspections, most recent first.
A resident at risk for pressure ulcers developed a facility-acquired Stage 3 PU on the left hip, which was first identified during an outpatient wound care consult. Despite regular skin assessments documented as intact, there was no evidence of wound assessment, measurement, or incident reporting by nursing staff upon the resident's return, and the DON was not notified. Facility policy requiring comprehensive wound documentation and investigation was not followed.
The facility did not conduct thorough investigations into significant injuries and adverse events involving three residents, including a new stage 3 pressure ulcer, an unwitnessed fall with head injury, and multiple unwitnessed falls with skin tears. In each case, required documentation, staff interviews, and root cause analyses were incomplete or missing, and the facility did not follow its own incident investigation policy to rule out abuse or neglect.
Failure to Prevent and Document Facility-Acquired Stage 3 Pressure Ulcer
Penalty
Summary
A resident was admitted to the facility with multiple diagnoses, including cirrhosis of the liver, lymphedema, difficulty walking, and weakness. Upon admission, assessments and documentation indicated that the resident did not have a pressure ulcer (PU) on the left hip, though the resident was identified as being at risk for developing PUs. The resident's baseline and comprehensive care plans noted skin concerns and risk factors, but there was no documentation of a left hip wound at admission. Routine skin assessments were scheduled twice weekly, typically on shower days, and staff were expected to document any skin alterations or breakdowns observed during these assessments. Despite these protocols, the resident developed a facility-acquired Stage 3 pressure ulcer on the left hip, which was first identified during an outpatient wound care physician visit. Prior to this consult, facility records and treatment administration records consistently indicated that the resident's skin was intact, and there was no evidence of a left hip wound. The wound care physician attributed the new ulcer to the resident's wheelchair being too small and recommended specific wound care interventions. However, there was no documented evidence in the facility's records of wound measurements or a detailed assessment of the new ulcer upon the resident's return from the consult, as required by facility policy. Interviews with nursing staff and facility leadership revealed that while skin assessments were performed and documented as intact, there was a lack of follow-up and documentation when the new Stage 3 pressure ulcer was identified. The nurse who received the resident after the wound care consult documented the new recommendations but did not record wound measurements or complete an incident report. The DON was not made aware of the new wound, and there was no investigation or documentation of the wound's development or progression. Facility policies required comprehensive documentation and assessment of new wounds, including measurements and incident reporting, but these steps were not followed in this case.
Failure to Conduct Thorough Investigations of Resident Injuries and Adverse Events
Penalty
Summary
The facility failed to ensure thorough investigations were conducted to rule out abuse or neglect for three residents who experienced significant adverse events. In the first case, a resident with cirrhosis, lymphedema, and mobility issues was found to have a new stage 3 pressure ulcer on the left hip during an outpatient physician visit. The wound was not present upon admission, and there was no documentation of the wound being measured or investigated upon the resident's return to the facility. Nursing staff and the DON confirmed that no incident report or investigation was completed, and the wound was not documented in the treatment administration records. In the second case, a severely cognitively impaired resident was found on the floor in a pool of blood after an unwitnessed fall, resulting in a head injury and emergency transfer to the hospital. The investigation provided by the facility was limited to a single report and statement, with no staff interviews or clear identification of the causal factor for the fall. The documentation did not address when the resident was last toileted or given fluids, despite the resident's dependence on staff for these needs. The DON was unable to provide further information regarding the root cause of the fall. The third case involved a resident with a history of falls and cognitive impairment who sustained two unwitnessed falls, one resulting in a skin tear in the bathroom with blood found at the bedside, and another skin tear during care by an agency CNA. Investigations into these incidents were incomplete, lacking statements from all relevant staff and failing to address key details such as the presence of blood by the bed and the circumstances of the skin tear during care. The DON and other facility leaders acknowledged that investigations did not fully determine the causal factors or rule out neglect, and the facility's own policy for incident investigation was not followed.
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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 Skillman
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Park Place Llc | 3.9 mi | ★★★★★ | 16 | 0 |
| Carnegie Post Acute Care At Princeton Llc | 4 mi | ★★★★★ | 1 | 0 |
| Merwick Care & Rehab Center, Llc | 5.3 mi | ★★★★★ | 4 | 0 |
| Bridgeway Care And Rehab Center At Hillsborough | 6.1 mi | ★★★★★ | 11 | 0 |
| Foothill Acres Rehabilitation & Nursing Center | 6.7 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.