Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Stonebrook Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple medical conditions developed a small discoloration near the outer right eye that a family member believed was a bruise. Nursing staff and the DON assessed the area and documented it as skin discoloration, obtained MD orders for monitoring, and added it to the care plan, but there was no documentation of how the discoloration occurred or that an investigation into an injury of unknown source was initiated. This response did not follow the facility’s abuse reporting policy, which requires thorough investigation and reporting of injuries of unknown origin.
The facility did not update or post daily nurse staffing information as required, leaving outdated staffing data displayed for an extended period. An LVN covering for the infection preventionist nurse, who was on vacation, failed to update the daily DHPPD postings, which was confirmed by both the LVN and the administrator. Facility policy requires daily posting of direct care staffing numbers for every shift.
The facility did not complete and submit a required investigation summary to the state agency within five days after an alleged abuse incident between two residents, despite reporting the event to authorities. The incident involved yelling and a physical interaction, with no injuries found after assessment. Facility policy requires timely reporting of such investigations, which was not met.
The facility failed to complete and transmit discharge MDS assessments for two residents upon their discharge. One resident, with a history of pleural effusion and atrial fibrillation, and another with a left radius fracture and type two diabetes, were discharged without the required MDS assessments. Staff interviews confirmed awareness of the 14-day submission requirement, yet the assessments were not completed or submitted.
Failure to Investigate and Report Injury of Unknown Origin Near Resident’s Eye
Penalty
Summary
The facility failed to investigate and report an injury of unknown origin after a family member observed a discoloration near a resident’s outer right eye and believed it to be a bruise. The resident had diagnoses including UTI, dysarthria, and muscle wasting/atrophy, and an MDS indicating severely impaired cognition with a BIMS score of 7. During interview, the resident could not recall how the discoloration occurred. The DON stated that when the family member reported a bruise on the resident’s head, she and the ADON assessed the area with the family member present and told the family it was not a bruise but a greenish discoloration from a vein. A treatment nurse also described the area as a skin discoloration that was being monitored. Clinical documentation showed a physician order dated 12/5/25 for skin discoloration beside the outer right eye, with instructions to observe for swelling, skin breakdown, and bleeding every shift for 30 days, and a care plan problem for altered skin integrity related to this discoloration. The Weekly Non-pressure Ulcer Observation Tool documented that the family member stated it looked like a bruise and measured the discoloration as 0.5 cm by 0.1 cm. Progress notes later documented that the discoloration had resolved and that the MD was made aware, but there was no documentation explaining how the discoloration was acquired or that an investigation into a possible injury of unknown source was conducted. This was inconsistent with the facility’s Abuse Reporting Policy, which defines injury of unknown source and requires immediate initiation and documentation of a thorough investigation and reporting of any allegation of abuse or injury of unknown source to appropriate authorities within the required timeframe.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the daily nurse staffing information as required, resulting in outdated information being displayed for an extended period. During an observation, it was found that the posted Census and Direct Care Service Hours Per Patient Day (DHPPD) form was dated 19 days prior to the observation date. Interviews with a licensed vocational nurse (LVN) revealed that the infection preventionist (IP) nurse, who was responsible for updating the DHPPD postings, had been on vacation, and the LVN covering the duty forgot to update the daily staffing information. The administrator confirmed that the DHPPD should be posted daily, and a review of the facility's policy indicated that direct care daily staffing numbers are to be posted for every shift.
Failure to Timely Submit Abuse Investigation Summary
Penalty
Summary
The facility failed to complete and submit an investigation summary regarding an alleged abuse incident that occurred between two residents. On the night of the incident, staff heard yelling and an argument between the two residents, leading to one resident being transferred to another room. The following morning, one resident reported to the DON and Social Services Director that her roommate had tapped her on the back of the head, making her uncomfortable. An assessment was conducted, and no injuries or pain were noted, and the primary physician was notified. Despite the incident being reported to the police, Ombudsman, and the state survey agency, the facility did not provide a written investigation summary to the state agency within the required five working days. The administrator confirmed that there was no fax transmittal confirmation for the five-day summary or investigation summary for the incident, except for a much later fax confirmation. The facility's policy requires prompt reporting and thorough investigation of abuse allegations, with findings reported to appropriate agencies within five working days, which was not followed in this case.
Failure to Complete and Transmit Discharge MDS Assessments
Penalty
Summary
The facility failed to complete and transmit discharge Minimum Data Set (MDS) assessments for two residents, which is a requirement upon their discharge from the facility. Resident #38 was admitted on December 13, 2023, with a medical history including pleural effusion, atrial fibrillation, and peripheral vascular disease. The resident was discharged on February 20, 2024, but there was no evidence of a completed discharge MDS in the medical record. Similarly, Resident #51, admitted on January 3, 2024, with a history of left radius fracture, type two diabetes mellitus, and morbid obesity, was discharged on February 17, 2024, without a completed discharge MDS. Interviews with facility staff revealed that the MDS Coordinator and the Director of Nursing were aware of the requirement to complete and submit discharge MDS assessments within 14 days of a resident's discharge. The MDS Coordinator mentioned that the facility's electronic medical record system generated reports indicating when MDS assessments were due. Despite this, the discharge MDS assessments for both residents were not completed or submitted as required, which was acknowledged by the facility's Administrator, who expected timely submission of MDS assessments by the nursing department.
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Nursing homes near Los Gatos
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woodlands Healthcare Center | 0.4 mi | — | 2 | 0 |
| Plum Tree Care Center | 0.5 mi | — | 0 | 0 |
| The Terraces Of Los Gatos | 0.9 mi | — | 0 | 0 |
| Childrens Hc Org No Ca -pediatric Hospital D/p Snf | 1 mi | — | 0 | 0 |
| Almaden Health And Rehabilitation Center | 1.1 mi | — | 1 | 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 August 2026) and official state health department websites.