Stonecreek Health and Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of facility policy, it was determined the facility failed to enter wound treatment orders upon receipt of the orders for two of 25 sampled residents (R)237 and R99. The findings include: Review of the facility policy titled, Clean Dressing Change dated 03/12/2024, revealed It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Further review revealed Physician's orders were to specify the type of dressing and frequency of changes. 1. Review of R237's record revealed the facility admitted the resident on 07/25/2024, from an acute hospital setting, with diagnosis that included a Stage 4 pressure ulcer of the sacrum; other pulmonary embolism (blood clot blocking artery in the lung) with acute cor pulmonale (type of acute right side heart failure), and unspecified severe protein calorie malnutrition. Review of the Brief Interview for Mental Status (BIMS) assessment revealed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility policy, the facility failed to have an effective system in place to ensure residents' safety and adequate supervision was provided to prevent accidents related to smoking in prohibited areas and smoking paraphernalia not being kept in secured locations for three residents (R) 7 and R48) out of twenty-five total sampled residents. R48 was observed smoking in a prohibited area, and R7, R14, and R48 were all observed with smoking paraphernalia lying on their beds and bedside tables and not secured in the bedside lockbox provided as required. In addition, the facility failed to ensure staff utilized a mechanical lift (as required) during transfer of R14. The findings include: Review of the facility policy titled, Accidents and Supervision dated 01/02/2020, with a revision date of 02/21/2024, revealed the resident environment was to remain as free of accident hazards as was possible, and they were to receive adequate supervision and assistive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure drugs and biologicals were stored in accordance with the manufacturer's specifications and accepted professional nursing principles and practices for one (1) of two (2) medication rooms audited. Observation on [DATE] at 10:40 AM, of the medication room that serviced rooms on the facility's 100 and 200 halls revealed one (1) open and undated multidose vial of medication and sixty-two (62) wound care products that were beyond the expiration date printed on the label. The findings include: Review of the facility's policy titled, Medication Administration with a revision date of [DATE], revealed medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state .and in accordance with professional standards of practice in order to prevent contamination or infection. Further review revealed the person administering the medication was to, Identify the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to maintain safe and sanitary infection control precautions during wound care for 1 of 3 residents sampled for wound care out of 25 totaled sampled residents, (R)237. The finding include: Review of the facility's policy, Infection Prevention and Control Program with a revision date of 02/01/2024, revealed the facility had established and maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment. Per review, the facility's infection prevention program was also to help prevent the development and transmission of communicable diseases and infections. Continued review revealed All staff were to assume all residents were potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Review of the facility's policy titled, Clean Dressing Change with a revised date of 03/12/2024, revealed it was the policy of the facility to provide wound…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility's policy, it was determined the facility failed to maintain clinical records in accordance with accepted professional standards for one of three (3) sampled residents (Residents #6). Review of Resident #6's Medication Administration Record (MAR) revealed staff failed to document that the resident received seventeen doses of Norco (Hydrocodone 5, Acteaminophen 325), from 09/27/2023 through 10/28/2023 on the MAR. However, only two doses of the medication were signed out on the Medication Administration Record (MAR). The findings include: Review of the facility's policy, Medication Administration, dated 11/01/2023, revealed that medications were administered by licensed nurses or other staff who were legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. Continued review revealed that staff would sign the medication administration record (MAR) after the medication was administered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately. However, not later than two (2) hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury for one (1) out of five (5) sampled residents, Resident #3. On [DATE], Resident #3 was noted to have bruising and increased pain to his/her right knee. An X-ray of the right knee was performed on [DATE], and review of the X-ray report dated [DATE] at 5:40 AM, revealed Resident #3 had an acute distal femur fracture with malalignment. However, there was no documented evidence the facility reported the injury incident as an injury of unknown origin. The findings include: Review of the facility policy, Abuse, Neglect, and Exploitation, dated [DATE] and revised on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and review of the facility's Abuse policy, it was determined the facility failed to conduct a thorough investigation concerning an injury of unknown origin which was diagnosed as a right distal femur fracture for one (1) of five (5) sampled residents reviewed for potential abuse, neglect and mistreatment, Resident #3. On [DATE], Resident #3 was noted to have bruising to his/her right knee and increased pain in the knee. An X-ray of the right knee was obtained on [DATE] and on [DATE] at 5:40 AM, the X-ray results noted Resident #3 had an acute distal femur fracture with malalignment. However, there was no documented evidence the facility investigated the incident as an injury of unknown origin. The findings include: Review of the facility policy, Abuse, Neglect, and Exploitation, dated [DATE] and revised on [DATE], revealed it was the facility's policy to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, Centers for Medicare and Medicaid Services (CMS)Resident Assessment Instrument (RAI) Manual, and review of facility policy, it was determined the facility failed to review and revise a comprehensive person-centered care plan for two (2) of fourteen (14) sampled residents reviewed for care plans, Residents #2 and #3. Record review revealed Resident #2's care plan was not revised after he/she exhibited refusal and noncompliance with care. On [DATE] Resident #3 was noted with bruising to the right knee and increased pain. An X-ray of the right knee was performed on [DATE] and resulted on [DATE] at 5:40 AM and indicated Resident #3 had an acute distal femur fracture with malalignment. However, there was no documented evidence that the facility revised the comprehensive care plan when the fracture occurred. Record review revealed Resident #3's care plan was not revised after he/she sustained a right distal femur fracture on [DATE]. Review of the CMS RAI Manual, Section 4.7 The RAI…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure medical records were accurately documented for one (1) of five (5) sampled residents, Resident #3. On [DATE] Resident #3 was noted with bruising to the right knee and increased pain. An X-ray of the right knee was performed on [DATE] and the results obtained on [DATE] at 5:40 AM, revealed Resident #3 had an acute distal femur fracture with malalignment. However, there was no documented evidence the facility notified the attending Physician until [DATE], nor that Hospice Services was notified. The findings include: Review of the facility policy, Charting and Documentation, revised 07/2017, revealed all services provided to the resident, progress towards the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition was to be documented in the resident's medical record. Review revealed medical records was to facilitate communication between the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record reviews, and facility policy review, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety. This deficient practice could put the 77 residents who receive meals from the facility kitchen at risk for nausea, vomiting, and foodborne illness. Oberservations during intial tour on 08/30/2021: A. Expired food was found in storage, and the Certified Dietary Manager (CDM) used expired three (3) compartment sink sanitizer test strips to verify concentration. B. Raw foods were found stored next to ready-to-eat foods in the walk-in refrigerator. C. Kitchen staff failed to label and date leftover items. D. Kitchen staff failed to practice proper hand washing techniques and glove use. E. Food was stored within six (6) inches of the floor and 18 inches of the ceiling. F. Kitchen staff failed to wear a complete hair covering at all times when in the kitchen. G. Dry storage food items were not sealed and were open to air. H. Personal items were found stored on food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and facility policy review, it was determined the facility failed to follow transmission-based precautions for source control and personal protective equipment (PPE) for four (4) of twenty-two (22) residents sampled for infection control (Resident #384, Resident #385, Resident #53 and Resident #21). This deficient practice occurred during the COVID-19 pandemic and had the potential to affect all residents by placing them at risk of COVID-19 transmission. The facility failed to ensure hand hygiene and other appropriate measures were taken by staff to prevent the transmission of disease during the medication pass. This affected three (4) (Residents #50, Resident #69, Resident #82 and Resident #76) of five (5) residents observed receiving medication and/or a finger stick blood sugar (FSBS) during the medication pass observation. The findings included: Review of the facility's policy, titled The Transmissions Based Precautions Policy, dated 03/22/2021, revealed in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews it was determined the facility failed to provide privacy covers for a urinary catheter drainage bag for two (2) of three (3) residents sampled for catheters (Resident #67 and Resident #79). The findings included: 1. Record review revealed Resident #67 was admitted to the facility 07/08/2021 with a diagnosis of acute kidney failure with tubular necrosis. Review of the Significant Change Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #67's Brief Interview for Mental Status (BIMS) score to be fifteen (15), which indicated the resident was cognitively intact. Further review of the MDS revealed Resident #67 had an indwelling catheter. Review of Resident #67's care plan, dated 07/08/2021, revealed the resident had a focus of having a catheter, with measurable goals and interventions. Observation on 08/30/2021 at 3:28 PM, revealed Resident #67 was in a reclining chair with his/her catheter hooked to the nightstand next to the chair. Further observation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and facility policy review, it was determined that the facility failed to ensure two (2) of three (3) sampled residents (Resident #32 and Resident #39) whose clinical records were reviewed for advanced directives had been provided information about advance directives and/or were offered assistance to formulate an advance directive, if desired. This had the potential to affect eighty-three (83) residents residing in the facility. The findings included: Review of the facility's policy, titled, Residents' Rights Regarding Treatment and Advance Directives, implemented 03/22/2021, revealed, It was the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. On admission, the facility would determine if the resident had executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive. The facility would provide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and facility policy review, it was determined the facility failed to ensure one (1) of thirty-eight (38) sampled residents (Resident #7) received an accurate assessment to reflect the resident at the time of the assessment. Specifically, the facility failed to accurately assess Resident #7's dental status. The findings included: Review of the Resident Assessment Instrument (RAI) Version 3.0 Manual on Coding Instructions, for section L0200, Oral/Dental Status, revealed that L0200B should be marked if the resident lacks all or parts of teeth, and L0200D should be marked if any cavity or broken tooth was seen. Record review revealed the facility admitted Resident #7 on 05/24/2021 with diagnoses which included atherosclerotic heart disease, type 2 diabetes, and hypertension. The admission Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was ten (10), which indicated moderate cognitive impairment. According…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, record reviews and facility policy review, it was determined the facility failed to include the diagnoses of anxiety disorder and bipolar disorder on the pre-admission screening and the resident review (PASRR) Level I. Further review revealed the facility failed to complete a Level II PASRR screening to include new mental health diagnoses of major depressive disorder and Schizophrenia for one (1) of two (2) residents sampled for PASRR level II (Resident #47). The findings included: Record review revealed the facility admitted Resident #47 on 08/05/2020 with diagnoses including anxiety disorder and bipolar disorder. Review of the diagnoses listed in the medical record, Resident #47 was diagnosed with major depressive disorder on 08/26/2020 and schizophrenia on 11/15/2020. Review of the 5-day Minimum Data Set (MDS) assessment, dated 07/29/2021, revealed the resident's Brief Interview for Mental Status (BIMS) score was fifteen (15), which indicated the resident was cognitively intact. Further review of the MDS revealed Resident #47 had diagnoses of anxiety, bipolar…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record reviews, and review of the facility's policy, it was determined the facility failed to ensure a comprehensive care plan was developed for one (1) of twenty-five (25) sampled residents reviewed for care plans (Resident #2). Specifically, the facility failed to have a care plan for the use and care of Resident #2's urinary catheter. The findings included: Review of the facility's policy, Care Plans, Comprehensive Person-Centered, revised December 2016, revealed the interdisciplinary team (IDT), in conjunction with the resident and family or legal representative, should develop and implement a comprehensive, person-centered care plan for each resident through analysis of the information gathered as part of the comprehensive assessment. Record review revealed the facility admitted Resident #2 on 09/22/2020 with diagnoses which included cerebral infarction (stroke) with neuromuscular dysfunction of the bladder. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 05/18/2021, revealed the facility assessed Resident #2's cognition as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and review of the facility's policy, it was determined the facility failed to review and revise the care plan after a fall for one (1) of two (2) sampled residents reviewed for falls (Resident #50). Specifically, the facility failed to update Resident #50's care plan with new interventions after falls. The findings include: Review of the facility's policy, titled, Falls Management Program Guidelines, undated, revealed the resident's care plan should be updated to reflect any new or change in interventions. Record review revealed the facility admitted Resident #50 on 07/20/2021 and readmitted the resident on 08/12/2021, with diagnoses which included altered mental status, congestive heart failure, epilepsy (seizures), unsteady gait, repeated falls, and wedge compression fracture of the first lumbar vertebra. Review of the admission Minimum Data Set (MDS), dated [DATE], revealed Resident #50's cognition was moderately impaired, with a Brief Interview for Mental Status (BIMS)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, record reviews, and facility policy reviews, it was determined that the facility failed to provide care and services according to professional standards of practice for one (1) of two (2) sampled residents reviewed for falls (Resident #50). Specifically, the facility failed to ensure nursing completed neurological (neuro) checks after Resident #50 had an unwitnessed fall on 07/21/2021 and failed to ensure nursing obtained new vital signs with each neurological check completed for Resident #50 after a fall on 08/04/2021. The findings included: Interview with the Director of Nursing (DON), on 09/02/2021 at 10:30 AM, revealed the facility did not have a policy specific to neurological checks. Record review revealed the facility admitted Resident #50 on 07/20/2021 and readmitted him/her on 08/12/2021, with diagnoses which included altered mental status, congestive heart failure, epilepsy (seizures), unsteady gait, repeated falls, and wedge compression fracture of the first lumbar vertebra. Review of the admission Minimum Data Set (MDS) assessment, dated 07/27/2021,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and review of facility policies, it was determined the facility failed to ensure residents were free from unnecessary psychotropic medications for two (2) residents of five (5) residents reviewed for unnecessary medications (Resident #2 and Resident #55). Specifically, the facility failed to monitor behaviors present for the use of psychotropic medications and offer non-pharmacological interventions for Resident #2; and failed to monitor Resident #55's behaviors when using an antipsychotic medication for depression. This deficient practice could affect the 11 residents who were being administered antipsychotic medications. The findings included: 1. Review of the facility's policy titled, Use of Psychotropic Drugs, implemented 03/22/2021, revealed the indications for the use of any psychotropic drug should be documented in the medical record and should include the specific condition as diagnosed by the physician, non-pharmacological interventions that have been attempted and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and facility policy review, it was determined the facility failed to provide dental services for one (1) of one (1) sampled resident (Resident #7) who had missing and broken teeth. The findings included: Review of the facility's policy, titled, Dental Services, dated December 2016, indicated that routine and emergency dental services were available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Record review revealed the facility admitted Resident #7 on 05/24/2021 with diagnoses which included atherosclerotic heart disease, type 2 diabetes, and hypertension. Review of the admission Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was ten (10), which indicated moderate cognitive impairment. According to the MDS, there were no issues with the resident's teeth. Review of the admission Nursing Bundle, document, revealed Resident #7 did not have any…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.