Average — CMS composite of the measures below.
The next survey window likely opens around March 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 Stonebridge Health Rehab during CMS and state inspections, most recent first.
Failure to provide adequate pain management for a resident with lung and brain cancer. A resident with severe cognitive impairment and frequent pain repeatedly told staff she was hurting and needed medication, including chest pain and headaches. Records showed inconsistent pain scoring, PRN oxycodone use, and a delayed fentanyl patch change, while the ADON acknowledged the pain assessments may not have reflected the resident’s actual pain and that she was not receiving pain medication often enough to stay ahead of it.
Incorrect dose and late administration of Zyprexa: A resident with severe cognitive impairment and bipolar disorder received Zyprexa 5 mg instead of the ordered 2.5 mg dose, and it was administered later than the scheduled time. Staff interviews showed awareness of the 8 rights of medication administration and the need to match the MAR to the label, but the observed med pass did not follow the ordered dose and time.
A resident with bowel and bladder incontinence, wounds, and EBP orders received peri-care that did not follow infection control procedures. Two CNAs used the same wipe for multiple strokes and folded wipes during care, and they did not wear gowns while providing high-contact care in an EBP room even though PPE was available at the door. Interviews confirmed staff knew the expected peri-care and PPE practices, but one CNA said she believed folding the wipe after each stroke was acceptable.
A resident with multiple medical conditions missed a scheduled outside medical appointment after the facility failed to arrange transportation, despite receiving timely notice from the responsible party. Documentation of the appointment was provided and reminders were given, but staff did not communicate the need for transportation to the SW, who was responsible for scheduling. The lack of clear communication and absence of staff education or policy on transportation procedures contributed to the missed appointment.
A resident with chronic pain was not provided scheduled Morphine and Tramadol due to delays in medication delivery, resulting in untreated pain and mental anguish. Despite repeated requests and severe pain levels, the facility staff failed to ensure timely administration of the prescribed medication, leading to prolonged suffering.
The facility's kitchen failed to meet food safety standards, with staff not wearing hair restraints, neglecting hand hygiene, and improperly sanitizing equipment. The dietary manager used inappropriate methods to clean thermometers, risking cross-contamination. Despite training, staff did not consistently follow safety protocols, leading to potential foodborne illness risks.
The facility failed to properly store and label medications, with expired items found in the medication storage room and on two medication carts. Additionally, a medication cart was left unlocked and unattended, posing a risk of unauthorized access. Staff interviews revealed a lack of clear responsibility for checking expiration dates and securing carts, despite facility policies requiring these actions.
The facility failed to prepare foods by methods that conserve nutritive value, flavor, and appearance. Food was prepared hours before service and held improperly, with pureed foods made without measuring tools and using water, resulting in bland flavors. Despite training, the Dietary Manager admitted to using inappropriate ingredients and methods, leading to poor quality. Quality Assurance reports highlighted repeated deficiencies in following menus and recipes, compromising food quality and resident safety.
A resident's privacy was compromised during wound care when an RN left the door and privacy curtain open, exposing the resident's buttocks to the hallway. The RN admitted to being nervous and not realizing the oversight, while the DON and ADM emphasized the importance of maintaining privacy and dignity. The facility's policy on resident rights was not followed.
A resident with a history of cerebrovascular disease and other conditions did not receive adequate respiratory care in a facility. Despite being on antibiotics and nebulizer treatments for an upper respiratory infection, necessary assessments and documentation of vital signs were not conducted. Facility staff interviews revealed inconsistencies in following policies for respiratory care, leading to a deficiency in care standards.
A resident with multiple health issues, including a pressure ulcer, did not receive proper infection control during wound care. The CNA and RN involved failed to follow enhanced barrier precautions, such as wearing gowns and properly handling contaminated materials. Despite being trained, both staff members admitted to lapses in protocol, which were acknowledged by the DON and ADM responsible for infection control oversight.
A facility failed to implement an effective antibiotic stewardship program, as evidenced by the case of a resident who was prescribed Azithromycin for a presumed URI without completing the required infection surveillance form. Despite the facility's policy mandating such documentation, the form was not completed, and the appropriateness of the antibiotic use was not evaluated. Interviews with staff revealed a lack of adherence to the policy, which could lead to unnecessary or inappropriate antibiotic use.
A facility failed to remove a resident's discontinued Hydrocodone from the medication cart, leading to its administration after discontinuation and eventual tampering. The resident, with moderate cognitive impairment and multiple diagnoses, received the discontinued medication in September and November 2023. The tampering was discovered during a narcotic count in March 2024.
Failure to Provide Adequate Pain Management
Penalty
Summary
The facility failed to ensure safe, appropriate pain management for a resident with lung cancer, brain cancer secondary to lung cancer, COPD, generalized anxiety disorder, and pain. The resident’s quarterly MDS reflected severe cognitive impairment, frequent pain, and difficulty sleeping because of pain. Her care plan identified PRN pain medication therapy related to cancer of the lung and brain, and physician orders included a fentanyl patch every 72 hours, oxycodone 20 mg every 2 hours as needed for pain, and pain monitoring every shift using an appropriate pain scale. Observation and record review showed the resident repeatedly reported pain and requested medication. On 04/21/2026, she sat in her doorway telling staff she was in pain, touching her chest and stating that was where she hurt and that she also had a very bad headache. Staff responded to her, and the MAR reflected PRN oxycodone administrations that evening and the following morning. The pain assessment tool on the treatment administration record documented pain as 0 on all three shifts for 04/21/2026, then 9 on the day and evening shifts for 04/22/2026. The MAR also showed the fentanyl patch was applied on 04/19/2026 and again on 04/22/2026. On 04/22/2026, the resident was observed in her wheelchair at her doorway saying she needed help and was in pain. She remained there for about an hour and a half, occasionally asking for help, while CNA J responded to her requests and assisted her to the bathroom once. No nurse was observed on the hall during that time. The ADON later stated she was working the floor because the scheduled nurse did not show up, that the resident was on hospice, and that the pain assessment zeros may not have properly reflected the pain the resident was experiencing. She also stated the resident had not received PRN pain medication all night and that the resident was not receiving pain medication as often as she might need to stay on top of her pain.
Incorrect dose and late administration of Zyprexa
Penalty
Summary
Resident #36, a female with diagnoses including Alzheimer's disease, anxiety disorder, unspecified bipolar disorder, dementia, history of falls, and psychophysiologic insomnia, had severe cognitive impairment with a BIMS score of 00 on the annual MDS. Her physician orders included Zyprexa 2.5 mg by mouth twice daily and Zyprexa 5 mg by mouth at bedtime for bipolar disorder. The MAR for April 2026 reflected the same scheduled doses and administration times of 7:00 a.m., 4:00 p.m., and 9:00 p.m. During observation of medication administration, MA G gave Resident #36 Zyprexa 5 mg at 8:34 a.m. instead of the ordered 2.5 mg dose. The same administration was also given at 8:34 a.m. instead of the ordered 7:00 a.m. time. The report states that MA G had been working as a CNA since 2018 and as a medication aide for about 5 to 6 months, and he said he had received medication administration training during onboarding. He stated that medication administration requires checking the order and the time the medication is to be given. Interviews with LVN B, MA F, the DON, and the ADM reflected that staff understood wrong-dose medication administration could negatively affect residents and that medication errors should be reported to nursing leadership. The facility policy stated that the MAR must be compared with the medication label before administration and that medication schedules should be followed, with medications generally administered within 60 minutes before or after the scheduled time. The deficiency was based on the observed administration of the incorrect dose and late administration of Resident #36's scheduled Zyprexa.
Infection Control Failures During Peri-Care and EBP Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program for Resident #22 during incontinent care and while providing care in a room designated for Enhanced Barrier Precautions (EBP). Resident #22 was an [AGE]-year-old male admitted on 03/25/26 with diagnoses including chronic atrial fibrillation, heart failure, and pulmonary fibrosis. His MDS assessment dated 03/28/26 showed a BIMS score of 12, dependence for toileting hygiene, and that he was always incontinent of both bladder and bowel. His care plan and orders reflected bowel and bladder incontinence, bilateral buttocks wounds, left heel wound care, groin rash treatment, and EBP for wounds. During observation of incontinent care, CNA H and CNA I entered the room after putting on PPE, washed their hands, and then donned clean gloves. CNA H cleaned the resident’s genital area first, then later cleaned the anal area after the resident had a bowel movement. The observation showed CNA H used one wipe for multiple strokes on the scrotum, and CNA I also used wipes by folding them and making additional swipes with the same wipe. The observation further showed CNA H and CNA I changed gloves and performed hand hygiene at intervals, but they removed gloves and gowns at the bedside and then repositioned the resident while their scrubs were touching the resident’s bedding. The observation also showed that although signage outside the room indicated EBP and PPE was stored at the door, CNA H and CNA I did not wear gowns while providing high-contact care to Resident #22. Interviews with LVN B, CNA H, CNA I, the DON, the ADM, and the ADON confirmed that staff were expected to use one wipe for one stroke, clean from front to back, and use PPE for residents on EBP. CNA I stated she thought folding the wipe after each stroke was acceptable because she had seen it in a peri-care training video. The facility’s infection control policy was requested on 04/21/26 but was not provided during the survey.
Failure to Arrange Transportation for Outside Medical Appointment
Penalty
Summary
A deficiency occurred when the facility failed to assist a resident in arranging transportation to an outside medical appointment, despite being given adequate notice. The resident, an adult male admitted for rehabilitation with diagnoses including infection of an internal joint prosthesis, COPD, and cardiac implants, had a scheduled follow-up appointment documented by an APRN. The appointment information was provided to the facility by the resident's responsible party both in writing and verbally, with reminders given the day before the appointment. Despite these notifications, transportation was not arranged for the resident. Interviews with facility staff revealed that the document containing the appointment details was uploaded and filed, but the information was not communicated to the social worker (SW), who was responsible for scheduling transportation. Multiple staff members, including the MDS nurse, ADON, and medical records staff, indicated that there was an expectation for nurses or CNAs to relay such information to the SW, but this did not occur. The SW confirmed she had not seen the appointment document and was not informed in time to arrange transportation, which required at least one to two days' notice. The facility did not have a documented in-service or policy regarding transportation procedures, and staff interviews indicated a lack of clarity and communication regarding responsibilities for arranging transportation. The resident missed the scheduled appointment as a result, although the appointment was later rescheduled. The admission agreement reviewed indicated that transportation responsibilities varied depending on the resident's payer source, but the process for ensuring timely arrangements was not followed in this instance.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide scheduled pain management for a resident, resulting in untreated pain and mental anguish. The resident, a male with a history of chronic pain syndrome, dementia, and other conditions, was admitted with physician orders for Morphine and Tramadol to manage his pain. However, the facility did not administer the prescribed Morphine from the time of admission, citing delays in receiving the medication from the pharmacy. This led to the resident experiencing significant pain, which was not adequately addressed by the alternative pain management provided. The resident's care plan included administering analgesia and evaluating the effectiveness of pain interventions, but these were not followed as the Morphine was not available. Despite the resident's repeated requests and expressions of pain, the facility staff failed to ensure the timely delivery and administration of the prescribed medication. The resident's pain was documented as severe, with a pain level of 10 out of 10, and he exhibited non-verbal signs of distress. Interviews with facility staff revealed communication errors and a lack of urgency in obtaining the necessary medication. The staff did not effectively coordinate with the pharmacy or the resident's physician to resolve the issue promptly. The facility's policies on pain assessment and medication delivery were not adhered to, resulting in the resident's prolonged suffering and a decrease in his quality of life.
Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food safety in its kitchen, as observed during a survey. The cook was not wearing hair restraints and did not practice appropriate hand washing before preparing and cooking food. Additionally, the cook did not wash hands or wear gloves when moving from one operation to another. Similarly, the dietary aide (DA) did not wash hands or wear gloves when transitioning between tasks. Non-dietary staff, such as a certified nursing assistant (CNA), entered the kitchen without hair restraints and did not wash hands, further compromising food safety. The dietary manager (DM) improperly cleaned the thermometer while checking food temperatures before meal service. The DM used used sanitizer wipes and then dipped the thermometer into a sanitation bucket containing murky water and cleaning cloths, which was not an appropriate method for sanitizing the thermometer. This thermometer was then used to check the temperature of food items, such as tomato soup and soft vegetables, potentially leading to cross-contamination. The DM admitted to using this process when running out of wipes, indicating a lack of proper knowledge regarding cleaning and sanitization of equipment. Interviews with staff revealed that despite receiving training on food safety practices, such as hand hygiene, wearing hairnets, and using gloves, these practices were not consistently followed. The DM acknowledged the risk of foodborne illnesses and cross-contamination due to these lapses in hygiene and safety protocols. The facility's quality assurance monitoring reports indicated that while some areas met expectations, there were recurring issues with the use of hairnets and sanitation practices, highlighting a need for further training and follow-up.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled according to professional principles in the medication storage room and on two medication carts. Observations revealed expired medications and supplies in the medication storage room, including a bottle of Senna S, alcohol wipes, a safety blood collection set, hypodermic needles, and blunt fill needles. Additionally, the 400 hall nurse's medication cart contained expired Ativan-Benadryl-Haldol compound syringes, Dimethacone body shield, Skintegrity Eco Hydrogel, Phytoplex Antifungal Ointment, PVP Povidone Iodine, and a honey-coated absorbent dressing. These expired items were not removed, indicating a lack of proper oversight and management of medication expiration dates. Furthermore, the 100-hall nurse's medication cart was left unlocked and unattended, posing a risk of unauthorized access to medications. During the observation period, several staff members, including the ADON, Administrator, and LVN A, walked past the unlocked cart without securing it. Interviews with staff revealed a lack of clarity regarding responsibility for checking expiration dates and securing medication carts. The ADON and DON acknowledged that multiple staff members were responsible for these tasks, but there was no specific person assigned to ensure compliance. The facility's policy required that medication carts be locked when unattended, but this was not consistently followed, leading to potential risks for residents.
Deficiencies in Food Preparation and Handling
Penalty
Summary
The facility failed to prepare foods by methods that conserve nutritive value, flavor, and appearance in the facility's only kitchen. Observations revealed that food was prepared 2 1/2 hours prior to meal service and held in a convection steamer or on a hot food table for more than 2 1/2 hours before being served. This included pureed and mechanical soft diet foods, which were prepared without measuring tools and without consideration of portion sizes to align with dietary needs. The pureed foods were prepared with water, and the liquids and thickeners used were not measured, resulting in a bland flavor. Interviews with the Dietary Manager (DM) indicated that he checks food temperatures 30 minutes before meal service and uses various ingredients to adjust the consistency and flavor of pureed foods. Despite training from the Registered Dietitian (RD) on maintaining nutritional value and using appropriate liquids for pureeing, the DM admitted to using other ingredients at times for flavor and pureeing foods. The DM also stated that he prepares food early and places it in the convection steamer or hot food table to keep on schedule, understanding it could result in poor quality. The facility's Quality Assurance (QA) Monitor Reports and audits conducted by the RD highlighted several areas where staff did not meet facility expectations, including not following menus as written, not using recipes, and not preparing puree with adequate and appropriate liquids. The reports also noted that dietary staff were redirected during evaluations to improve quality and safety, ensuring facility practices are achieved. However, the repeated deficiencies in food preparation and handling practices could compromise the nutritive value of food and place residents at risk of recovery from illness or injury.
Failure to Maintain Resident Privacy During Wound Care
Penalty
Summary
The facility failed to ensure the privacy of a resident during personal care, specifically during wound care provided by an RN. The incident involved a female resident with multiple medical conditions, including a right above-knee amputation and an unhealed pressure ulcer. During the wound care procedure, the RN left the resident's buttocks exposed to the hallway by not closing the door and privacy curtain. This exposure occurred when the RN opened the privacy curtain to retrieve supplies, and another resident opened the room door, leaving the resident's buttocks visible to anyone passing by. Interviews with the involved RN, the Director of Nursing (DON), and the Administrator (ADM) confirmed the breach of privacy. The RN acknowledged being trained on resident rights, including the right to privacy, and admitted to being nervous and not realizing the oversight at the time. The DON and ADM emphasized the importance of maintaining resident privacy and dignity, noting that failure to do so could have emotional impacts on the resident. The facility's policy on resident rights, which includes the right to privacy and confidentiality, was not adhered to during this incident.
Inadequate Respiratory Care and Documentation for a Resident
Penalty
Summary
The facility failed to provide adequate respiratory care for a resident, identified as Resident #22, who required such care. The resident, an elderly female with a history of cerebrovascular disease, vascular dementia, muscle weakness, hypertension, urinary retention, and hyperlipidemia, was admitted to the facility and was receiving treatment for an upper respiratory infection. Despite being on antibiotics and receiving nebulizer treatments, the facility did not conduct or document necessary physical assessments, including vital signs and lung sounds, before and after administering medications. The deficiency was identified through a review of Resident #22's medical records, which showed a lack of documented vital signs such as heart rate, oxygen saturation, respiratory rate, and temperature on multiple dates when nebulizer treatments were administered. Interviews with facility staff, including the Director of Nursing (DON) and Licensed Vocational Nurses (LVNs), revealed inconsistencies in the understanding and implementation of the facility's policy regarding the assessment and documentation of vital signs for residents receiving respiratory treatments and antibiotics. The facility's policy and competency guidelines required thorough assessments and documentation of vital signs and lung sounds when administering nebulizer treatments. However, these procedures were not followed, as evidenced by the absence of documented assessments in the resident's medical records. This failure to adhere to professional standards of practice could increase the risk of adverse reactions to medication for the resident.
Inadequate Infection Control During Wound Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the improper handling of wound care for a resident. The resident, an elderly female with multiple diagnoses including a urinary tract infection, chronic heart failure, and a pressure ulcer, was not provided with the necessary enhanced barrier precautions during wound care. The care plan for the resident did not include enhanced barrier precautions, despite physician's orders specifying the need for gown and glove use during high-contact care activities. During an observation, it was noted that a CNA and an RN did not adhere to the required infection control measures. The CNA assisted with positioning the resident without wearing a gown, and the RN failed to properly secure her gown and placed contaminated gauze on a clean supplies field. Both staff members acknowledged their training in enhanced barrier precautions but admitted to lapses in following the protocols, which could lead to cross-contamination and infection. Interviews with the DON and ADM revealed that they were responsible for ensuring compliance with infection control measures. The DON confirmed that staff were expected to wear gowns and gloves for residents requiring enhanced barrier precautions, and acknowledged the mistakes made by the CNA and RN. The facility's policies and training documents outlined the correct procedures for donning PPE and maintaining a clean field during wound care, which were not followed in this instance.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, specifically lacking an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. This deficiency was identified in the case of Resident #22, who was prescribed Azithromycin for a presumed upper respiratory infection (URI) without completing the required infection surveillance form. The absence of this form meant that the appropriateness of the antibiotic use was not evaluated, contrary to the facility's policy. Resident #22, an elderly female with a history of cerebrovascular disease, vascular dementia, muscle weakness, hypertension, urinary retention, and hyperlipidemia, was admitted to the facility and later treated for a cough with Azithromycin and Prednisone. Despite the treatment, there was no care plan related to the URI, and the infection surveillance form was not completed as per the facility's policy. The Director of Nursing (DON) justified the omission by stating that the infection did not meet the McGeer criteria, which is used to support healthcare-associated infection surveillance. Interviews with facility staff, including LVN C and LVN A, revealed a lack of adherence to the facility's antibiotic stewardship policy. Both LVNs indicated that the infection surveillance form should always be completed when antibiotics are prescribed, yet it was not done in this case. The facility's policy, revised in December 2016, mandates that all clinical infections treated with antibiotics undergo review and documentation using a facility-approved antibiotic surveillance tracking form. The failure to follow this policy could lead to unnecessary or inappropriate antibiotic use, increasing the risk of multi-drug resistant organisms among residents.
Failure to Remove Discontinued Narcotics Leads to Medication Diversion
Penalty
Summary
The facility failed to properly store and label biologicals for one resident, leading to a medication diversion incident. Specifically, the facility did not remove the resident's narcotics (Hydrocodone) from the medication cart when it was discontinued in July 2023. This oversight resulted in the administration of the discontinued medication on two occasions and the eventual tampering of the medication blister pack, which was discovered on March 9, 2024. The resident involved was a [AGE] year-old female with diagnoses including unspecified dementia, repeated falls, scoliosis, delusional disorders, and major depressive disorder. Her quarterly MDS assessment indicated a moderate cognitive impairment, and her care plan included administering pain medications as ordered by the physician. Despite the discontinuation order for Hydrocodone in July 2023, the medication remained on the cart and was administered in September and November 2023. The tampering was discovered during a narcotic count when two doses of Hydrocodone were found to be replaced with different medications and taped closed. The facility's investigation confirmed that the medication should have been removed from the cart when the order was discontinued. Interviews with nursing staff revealed that they were unaware of the tampering and had not removed the discontinued medication from the cart, as required by protocol.
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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 Austin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park Manor Bee Cave | 6.5 mi | ★★★★★ | 8 | 0 |
| Brush Country Nursing And Rehabilitation | 6.6 mi | ★★★★★ | 23 | 1 |
| Querencia At Barton Creek | 6.7 mi | ★★★★★ | 6 | 0 |
| West Oaks Nursing And Rehabilitation Center | 7.2 mi | ★★★★★ | 13 | 0 |
| Marbridge Villa | 8.3 mi | ★★★★★ | 0 | 0 |
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