Above average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Health & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that staff failed to follow infection control policies during medication administration by handling medications with bare hands, did not implement Enhanced Barrier Precautions for a resident with a pressure ulcer during wound care, and did not maintain required infection surveillance records for several months. These actions were confirmed by facility leadership and were in direct violation of established facility policies.
A resident with a history of a stage 3 heel pressure ulcer was observed multiple times not wearing physician-ordered prevalon boots, instead wearing sneakers provided by family. Staff continued to document in the MAR that the boots were in use, and the care plan and physician's order were not updated to reflect the family's request for the resident to wear shoes. The deficiency was identified through observations, record review, and staff interview, revealing a failure to provide care consistent with professional standards for pressure ulcer prevention.
A resident with a history of stroke and limited mobility did not have a physician-ordered hand splint applied as required, despite documentation indicating it was in place. Observations and interviews revealed the splint was not used as ordered, and there was confusion among staff regarding the status of the order, with no evidence of proper discontinuation prior to therapy ending.
Three residents did not receive scheduled medications, including IV antibiotics, pain medications, anti-androgen therapy, and anti-seizure drugs, due to unavailability and delays in pharmacy delivery. Staff did not promptly notify providers or utilize available alternative doses, and documentation of delivery discrepancies was lacking. Interviews confirmed ongoing issues with medication delivery and order discrepancies.
A resident with a right heel pressure ulcer did not receive prescribed wound care treatments on multiple occasions because an LPN withheld care pending order clarification, which was not pursued for several days. The DON confirmed that treatments should have been provided as ordered and clarified promptly if needed.
Two residents with severe cognitive impairment and dependence on staff for ADLs consistently received bed baths instead of scheduled showers, with no documentation of refusals or bathing preferences, contrary to facility policy and expectations communicated by nursing leadership.
A facility failed to reconcile pre-discharge medications with post-discharge medications in a resident's discharge summary, as required by their Discharge Planning Policy. The resident, who had diagnoses of cerebral infarction and anxiety, was discharged without this reconciliation documented. This deficiency was confirmed by the DON.
A resident with limited mobility, diagnosed with hypertension, CHF, and depression, was not consistently assisted with her daily walking program as per her care plan. Despite her requests and documented goals to walk 50 feet daily with assistance, facility records showed multiple instances of non-performance or missing documentation. The DON attributed this to a recent change in electronic medical records, but no further information was provided to resolve the issue.
A resident on contact precautions for MRSA and proteus mirabilis was not properly managed by staff, who failed to use PPE and perform hand hygiene as required. Observations showed that Nursing Assistants entered the resident's room without gloves or gowns and did not sanitize hands after assisting with meals, contrary to facility policy.
Deficiencies in Infection Control Practices and Surveillance
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's infection prevention and control practices. During medication administration, an LPN was observed preparing and administering medications to two residents by dispensing tablets directly into their bare hands before placing them into medication cups. This practice was in direct violation of the facility's policy, which states that medications should not come into contact with any surface except the medication cup and that staff should avoid touching medications with bare hands. The Nursing Home Administrator confirmed that staff are required to follow this policy. Additionally, the facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an unstageable pressure ulcer. Observations revealed that there was no signage on the resident's door indicating EBP, and during wound care, staff wore gloves but did not don a gown as required by the facility's EBP policy. The staff member performing wound care acknowledged uncertainty about the need for a gown due to the absence of signage, and the DON later confirmed that EBP should have been in place for this resident and that a gown should have been worn during wound care. The facility also failed to maintain an accurate infection surveillance data collection system. Review of the Antibiotic Use Tracking Log showed that no tracking was completed for a six-month period, from October 2024 through March 2025, despite the facility's policy requiring monthly documentation of antibiotic use and related infection data. The DON confirmed that the tracking log was not completed for those months.
Plan Of Correction
Preparation and submission of this plan of correction does not constitute an admission of, or agreement with, it is required by State and Federal Law. It is executed and implemented as a means to continuously improve the quality of care to comply with the state and federal requirements. 1. Residents 18 and 38 had an assessment completed, no ill effects were identified from the cited past deficient medication administration practice. Resident 44 had an assessment completed, no ill effects were identified from the cited past deficient practice regarding failure to follow enhanced barrier precautions. There were no residents affected by the cited past deficient practice related to incomplete Antibiotic Use Tracking Logs. 2. All residents have the potential to be affected by the cited past deficient medication administration practice. To identify others with the likelihood to be affected, the DON/designee completed a house-wide audit to ensure all residents that require enhanced barrier precautions have an order, signage, and an isolation caddy containing necessary PPE. Any missing necessary items will be immediately corrected. To identify others with the likelihood to be affected, the DON/designee completed an antibiotic order audit from the date of exit to present, ensuring that all new antibiotic orders are captured on the Antibiotic Use Tracking Log. The log will be updated with any orders that were inadvertently missed. 3. To prevent a future reoccurrence, the DON/designee will educate all licensed staff on the proper pouring of medications during med pass, ensuring medications do not come in contact with any other surface except the inside of the medication cup. To prevent a future reoccurrence, the DON/designee will educate all licensed nursing staff on the conditions that require enhanced barrier precautions, to ensure an order, signage, and an isolation caddy are present reflecting same. To prevent a future reoccurrence, the DON/designee will educate the Infection Preventionist on the proper completion of the Antibiotic Use Tracking Log. 4. To monitor and maintain ongoing compliance, the DON/designee will observe 3 random licensed nurses administering medications to one resident, ensuring medications poured during med pass do not come in contact with any other surface except the inside of the medication cup. Any deficient practice identified will be immediately corrected. This will occur weekly for 4 weeks and then monthly for 2 months. To monitor and maintain ongoing compliance, the DON/designee will audit 5 random residents requiring enhanced barrier precautions, ensuring an order, signage, and isolation caddy are present. Any missing items will be immediately corrected. This will occur weekly for 4 weeks and then monthly for 2 months. To prevent a future reoccurrence, the DON/designee will educate the Infection Preventionist on the proper completion of the Antibiotic Use Tracking Log. To monitor and maintain ongoing compliance, the DON/designee will complete an audit of 3 random antibiotics ordered, ensuring the necessary information is present on the Antibiotic Use Tracking Log for the initiation of the antibiotic. Any missing information will be immediately corrected weekly for 4 weeks, and then monthly for 2 months. All findings will be reported to the QA committee monthly for any further necessary recommendations.
Failure to Ensure Accurate Implementation and Documentation of Pressure Ulcer Prevention Orders
Penalty
Summary
A deficiency was identified when a resident with a history of chronic kidney disease and hyperlipidemia, who previously had a stage 3 pressure wound on the right heel, was observed multiple times not wearing prevalon boots as ordered by the physician. Instead, the resident was seen sitting in a wheelchair wearing sneakers during several observations. The physician's order and care plan both specified that prevalon boots were to be worn at all times to promote healing and prevent further skin breakdown. Despite these orders, the Medication Administration Record (MAR) indicated that staff documented the resident as having the prevalon boots on during all shifts, which was inconsistent with direct observations. The care plan also included an approach for the resident to wear prevalon boots at all times, and this was based on a physician's recommendation following a foot and ankle consult. There was no documentation in the clinical record prior to the removal of the order and care plan approach that the resident or family had requested the use of sneakers instead of the boots. The deficiency was further supported by a nursing progress note written after the observations, which stated that the resident's heel wound had healed and that the family had provided shoes for the resident to wear. However, the physician's order and care plan were not updated at the time the family made this request, and staff continued to document that the boots were in use when they were not. The facility administrator confirmed that he would have expected staff to accurately document the use of the boots and to update the physician's order and care plan in response to the family's request.
Plan Of Correction
Preparation and submission of this plan of correction does not constitute and admission of, or agreement with, it is required by State and Federal Law. It is executed and executed and implemented as a means to continuously improve the quality of care to comply with the state and federal requirements. 1. Resident 47 had no ill effects from the cited past deficient practice. During the survey, Attending Physician was contacted for clarification, order was obtained to discontinue prevalon boots, care plan was updated. 2. To identify others with the likelihood to be affected, the DON/designee completed a house-wide audit of care plans/orders to identify all residents ordered prevalon boots. Assessments were completed on all the Residents identified, need for prevalon boot was reviewed with MD, and care plan was updated with any further recommendations received. 3. To prevent a future reoccurrence, the DON/designee will educate all nursing staff to ensure documentation completed for a Resident reflects the plan of care observed in place. 4. To monitor and maintain ongoing compliance, the DON/designee will audit 5 random residents with a care plan approach for prevalon boots observing that documentation completed reflects the plan of care visualized in place, weekly x 4 and then monthly x 2. Any inaccurate findings will be corrected immediately, and findings will be reported to the QA committee monthly, for any further necessary recommendations.
Failure to Ensure Proper Use of Splint for Resident with Limited Mobility
Penalty
Summary
The facility failed to ensure that a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility, as required by regulation. The resident, who had a history of stroke and elevated blood pressure, had a physician's order and care plan in place for a left hand splint to be worn at all times, with removal only for care and skin monitoring. Despite these orders, multiple observations over two days revealed that the resident's left hand splint was not in place, and the resident confirmed that staff had not applied the splint. The splint was observed in a basket on the resident's bedside dresser during this time. Documentation in the Medication Administration Record (MAR) indicated that the splint was signed off as being on during each shift, except for a few instances marked as refused by the resident. However, interviews with facility leadership revealed confusion regarding the status of the splint order, with the DON referencing a progress note from two months prior about the splint being on hold due to swelling, but no current orders or documentation supporting discontinuation of the splint prior to the most recent therapy note. Occupational therapy documentation indicated the splint should continue until therapy was discontinued, and there was no evidence of a physician order to discontinue the splint before July. This discrepancy between documentation, staff actions, and physician orders led to the deficiency.
Plan Of Correction
Preparation and submission of this plan of correction does not constitute an admission of, or agreement with, it is required by State and Federal Law. It is executed and implemented as a means to continuously improve the quality of care to comply with the state and federal requirements. 1. Resident 48 had no ill effects from the cited past deficient practice. During the survey, Attending Physician was contacted for clarification, order was obtained to remove splint on left hand, care plan was updated. 2. To identify others with the likelihood to be affected, the DON/designee completed a house-wide audit to identify all residents ordered splints. Assessments were completed on all residents identified, to ensure any splints ordered are in place and not causing skin impairment. Splint was reviewed with the therapy dept and attending physician, plan of care was updated reflecting any further recommendations received. 3. To prevent a future reoccurrence, the DON/designee will educate all nursing staff to ensure documentation completed on splinting for a resident reflects the plan of care observed in place, and follows physician orders. If splint is held by physician, order will be transcribed to current plan of care ordered. 4. To monitor and maintain ongoing compliance, the DON/designee will audit 5 random residents with splints to ensure the resident is free of skin impairment related to splint, and the documentation completed reflects plan of care observed, weekly x 4 weeks and then monthly x 2. Any inaccurate findings will be corrected immediately, and findings will be reported to the QA committee monthly, for any further recommendations.
Failure to Provide Timely Pharmaceutical Services and Medications
Penalty
Summary
The facility failed to provide routine drugs and biologicals to meet the needs of three residents, as required by policy and regulation. For one resident admitted with orbital eye cellulitis and lower back pain, there were missed doses of IV antibiotics and pain medications due to unavailability upon admission. The medication administration record (MAR) documented four missed IV antibiotic doses and several missed doses of morphine-based pain medications, with notes indicating the medications were unavailable. Nursing progress notes showed that the provider was not notified of the missed doses until the following day, and the pharmacy later reported that one medication was on backorder, leading to a change in the pain management plan. Another resident, admitted with malignant neoplasm of the prostate and generalized weakness, had a physician order for Casodex that was not administered for two scheduled doses due to unavailability. The MAR reflected these missed doses, and corresponding notes indicated the medication was not available on the first two days after admission. Similarly, a third resident with epilepsy and multiple sclerosis did not receive two scheduled doses of Lacosamide, an anti-seizure medication, because the medication was not delivered with the initial pharmacy shipment. Nursing notes confirmed the delay and documented communication with the provider and pharmacy regarding the missing medication. Interviews with staff, including a registered nurse, the Nursing Home Administrator (NHA), and the Director of Nursing (DON), revealed ongoing issues with delayed medication deliveries and order discrepancies. Staff acknowledged that it was their responsibility to address these issues with the pharmacy and provider when discovered. Facility documentation showed scheduled pharmacy deliveries, but the NHA and DON were unable to provide specific reasons for the delays or documentation of delivery discrepancies. The DON noted that an alternative dose of a medication was available onsite but was not utilized because the provider was not contacted promptly.
Failure to Administer Ordered Pressure Ulcer Treatment Due to Lack of Order Clarification
Penalty
Summary
The facility failed to provide necessary treatment and services to promote the healing of a pressure ulcer for one resident. According to the facility's Clean Dressing Change Policy, wounds are to be dressed using a clean technique, with new dressings applied as ordered and findings documented. The resident in question had a diagnosis of a right heel pressure ulcer and osteoarthritis, with physician orders specifying a wound care regimen involving cleansing, application of betadine and calcium alginate, and securing with an ABD pad three times daily. Clinical record review showed that the prescribed wound treatments were not administered during several night shifts, as documented in the Medication Administration Record. An LPN reported not administering the treatments because the evening shift had noted the need for order clarification, but no clarification was sought throughout the week, resulting in continued omission of care. The DON confirmed that wound treatments should have been administered as ordered and clarified in a timely manner if needed.
Failure to Provide and Document Required Showers for Dependent Residents
Penalty
Summary
The facility failed to provide necessary services to maintain adequate personal grooming for two residents who were dependent on staff for assistance with activities of daily living. Both residents had significant cognitive impairments, including dementia and severe communication limitations, and were scheduled to receive showers on specific days. However, clinical record reviews showed that both residents consistently received bed baths instead of showers on their scheduled shower days over a period of more than a month. There was no documentation in the clinical records or progress notes indicating that either resident refused showers on those days, nor was there evidence that their bathing preferences were assessed or documented as required by facility policy. Interviews with facility leadership confirmed that staff are expected to ask residents about their bathing preferences and to document any refusals, with non-verbal residents to be provided showers unless they give non-verbal cues of refusal. Despite these expectations, the records for both residents lacked documentation of refusals or alternative arrangements, and the required communication and documentation protocols were not followed. This resulted in a failure to adhere to facility policy and regulatory requirements for providing and documenting appropriate personal care services.
Failure to Reconcile Medications in Discharge Summary
Penalty
Summary
The facility failed to include a reconciliation of all pre-discharge medications with the resident's post-discharge medications in the discharge summary for one of the closed records reviewed. The facility's Discharge Planning Policy, revised on September 24, 2020, mandates that a discharge summary should include a reconciliation of all pre-discharge medications with the resident's post-discharge medications, both prescribed and over-the-counter. However, upon reviewing the clinical record of a resident diagnosed with cerebral infarction and anxiety, it was found that the discharge summary dated May 31, 2024, did not contain this required medication reconciliation. This deficiency was confirmed during an interview with the Director of Nursing on June 13, 2024.
Failure to Assist Resident with Mobility Goals
Penalty
Summary
The facility failed to ensure that a resident with limited mobility received appropriate services and assistance to maintain or improve mobility. Resident 22, who has diagnoses including hypertension, congestive heart failure, and depression, expressed a desire to walk at least once a day. However, she reported that staff did not always assist her in doing so. This concern was reiterated during a resident group interview. The resident's care plan and restorative nursing orders included a goal for her to ambulate 50 feet per day with assistance, but documentation revealed multiple instances where this was not performed or not documented. The facility's records showed that on several occasions in April, May, and June 2024, there was either no documentation or it was noted that the walking program was not performed for Resident 22. During interviews, the Nursing Home Administrator and Director of Nursing were informed of the resident's statements and the lack of documentation. The Director of Nursing suggested that the recent change in electronic medical records providers might have contributed to the missing documentation. Despite being made aware of the issue, no additional information was provided to address the resident's concerns.
Inadequate Infection Control Practices Observed
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the improper use of Personal Protective Equipment (PPE) and inadequate hand hygiene practices by staff members. Specifically, the facility's policy on Transmission-Based Precautions was not adhered to, as observed with Resident 46, who was on contact precautions due to a Methicillin-resistant Staphylococcus aureus (MRSA) infection and proteus mirabilis. Despite the presence of a contact precaution sign on the resident's door, staff members, including Nursing Assistants, entered the room without donning gloves or gowns and failed to perform hand hygiene after exiting the room or after assisting the resident with meal setup and clothing protectors. Observations revealed that staff members repeatedly neglected to follow proper infection control protocols, such as wearing gloves and gowns when necessary and performing hand hygiene after resident contact or potential contamination. Interviews with the Registered Nurse and Director of Nursing confirmed that the expected procedures were not followed, particularly during meal service for Resident 46. The failure to utilize PPE and complete hand hygiene was acknowledged by the facility's administration, but no additional information or corrective measures were provided at the time of the survey.
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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 Duncannon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Transitions Healthcare Allens Cove | 3.1 mi | ★★★★★ | 8 | 0 |
| Premier At Perry Village For Nursing And Rehab, Ll | 6.1 mi | ★★★★★ | 14 | 0 |
| Northern Dauphin Nursing And Rehabilitation Center | 12.3 mi | ★★★★★ | 2 | 0 |
| Amoroso Healthcare And Rehabilitation Woodridge | 12.5 mi | ★★★★★ | 16 | 1 |
| Gardens At West Shore, The | 12.6 mi | ★★★★★ | 5 | 1 |
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