StoneCreek Health and Rehabilitation

Based on observation and staff interviews, the facility failed to ensure a Dietary Aide with facial hair wore a facial hair covering while handling and preparing food in the kitchen for 1 of 4 Dietary Aides observed (Dietary Aide #1). This practice had the potential to contaminate food served to residents. The findings included:On 6/16/26 at 11:19 AM, Dietary Aide #1 was observed removing a tray of rolls from the oven, placing the tray on a workstation, and applying butter to the rolls. Dietary Aide #1 had facial hair (beard and mustache) and was not wearing a facial hair covering. His facial hair was approximately a quarter of an inch in length. During an interview on 6/16/26 at 11:21 AM, Dietary Aide #1 reported he knew he should have been wearing a facial hair covering and forgot to put one on before handling food. An interview on 6/16/26 at 11:22 AM with the Dietary Manager revealed Dietary Aide #1 should have been wearing a facial hair covering and that dietary staff were expected to wear the appropriate hair covering while preparing food.An interview on 6/17/26 at 1:39 PM with…

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 record review, observations and interviews with resident, family member, staff and Physician Assistant, the facility failed to prevent urinary catheter bags from touching the floor to reduce the risk of infection for 2 of 2 residents (Resident #2 and Resident #72) reviewed for urinary catheters. The findings included: 1. Resident #2 was admitted to the facility on [DATE] with diagnoses that included obstructive and reflux uropathy (blockage that causes urine to back up). Resident #2's care plan started on 4/28/26 indicated Resident #2 required a suprapubic urinary catheter related to obstructive uropathy. Interventions included to position bag below level of bladder. The admission Minimum Data Set assessment dated [DATE] indicated Resident #2 was cognitively intact, had no rejection of care behaviors and had an indwelling catheter. Resident #2 was frequently incontinent of bowel. An observation was made of Resident #2 on 6/14/26 at 2:44 PM while he was lying in bed in his room. Resident #2 had an…

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 record review, observations and interviews with staff and the Physician Assistant, the facility failed to maintain a medication error rate of less than 5% as evidenced by the omission of a medication and the administration of the wrong dosage (2 medication errors out of 33 opportunities), resulting in a medication error rate of 6.06% for 1 of 4 residents (Resident #100) observed during medication pass.The findings included:Resident #100 was admitted to the facility on [DATE] with diagnoses that included anemia, muscle weakness and depression.The physician's orders in Resident #100's electronic medical record indicated active orders for:2/25/26 - B Complex Plus Vitamin C one tablet oral once a day (supplement).4/19/26 - Sertraline (an antidepressant) 25 milligrams (mg) 3 tablets oral once a day for depression. Administer with 100 mg tablet to equal 175 mg.On 6/16/26 at 8:21 AM, Medication Aide (MA) #1 was observed as she prepared Resident #100's medications. MA #1 prepared a total of 6 pills in a…

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 record review, observation and staff interviews, the facility failed to implement their infection control policies when Nurse Aide #2 failed to change gloves and perform hand hygiene during incontinence care on Resident #2. This deficiency occurred for 1 of 5 staff members reviewed for infection control practices (Nurse Aide #2).The findings included:A review of the facility's policy titled Hand Hygiene, implemented on 1/2/26 indicated: Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table.Under the Hand Hygiene Table, staff were required to use either soap and water or alcohol-based hand rub when performing the following tasks:After handling contaminated objectsBefore and after handling clean or soiled dressings or linensAfter handling items potentially contaminated with blood, body fluids, secretions, or excretionsWhen, during resident care, moving from a contaminated body site to a clean body siteAfter assistance with personal body functions (e.g. elimination, hair grooming, smoking)An…

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 and interviews with staff, the facility failed to remove expired food from 1 of 3 kitchen refrigerators (walk-in refrigerator) and remove food that was past the use by date on the packaging in the dry food storage area. The facility also failed to clean 3 of 3 food storage bin scoop holders and to label those bins with use by dates. These practices had the potential to affect food served to residents. Findings included: a. On 4/6/25 at 10:03 AM an observation in the walk-in refrigerator with the Dietary Manager (DM) found a sealed bag of pre-packaged chopped celery with a use by date of 3/31/25 located on the second shelf. The DM stated during the observation the celery should have been removed and had been overlooked by her. b. On 4/6/25 at 10:16 AM an observation with the DM in the kitchen found 3 large plastic storage bins on wheels with one labeled flour, one labeled sugar and one labeled rice. The bin labeled sugar was located in the food prep area of the kitchen and was approximately 25% full. The sugar bin did not contain an open date or a use by date.…

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, record reviews, staff interviews, and Wound Care Consultant Nurse Practitioner (NP) interviews, the facility failed to obtain orders, and to provide treatment on admission for two mid-spine pressure ulcer wounds for 1 of 3 residents (Resident #61) reviewed for pressure ulcers. Finding included: Resident #61 was admitted to the facility on [DATE] with diagnoses which included aftercare following joint replacement surgery and unspecified dementia. The admission Observation Detail report dated 3/15/25 at 3:37 PM by Nurse #1 revealed skin color normal, skin temperature warm, and skin moisture dry. Alterations in skin were noted as a surgical incision with the location as left shoulder wound vac. No other skin alterations were noted. An interview on 4/07/25 at 3:18 PM with Nurse #1 revealed she had completed Resident #61's admission Observation Detail report and her admission skin assessment. She stated she left out the two mid upper spine wounds in error. She stated the resident had a dressing…

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, record review, staff interviews, the facility failed to secure medications when Nurse #2, Nurse #3, and Nurse #4 left medications at the bedside for 2 of 2 residents observed with medications at the bedside (Resident #78 and Resident #83). Findings included: 1. Resident #78 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #78 was cognitively intact. There was not an assessment for medication self- administration documented in Resident #78's electronic medical record. On 4/6/25 at 9:56 AM an observation and interview were completed of Resident #78 and his room. Resident #78 was observed lying in his bed with his bedside table positioned next to his bed. A medication cup was observed sitting on his bedside table containing multiple pills. He had a small plastic cup filled with water sitting next to the medication cup. Resident #78 stated the nurse always left his pills for him to take. Resident #78 placed the pills from…

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 record review and interviews with resident, staff, Consultant Pharmacist, and the Medical Director (MD), the Consultant Pharmacist the facility failed to ensure an approved gradual dose reduction (GDR) was implemented and provide a recommendation during subsequent medication regimen reviews (MRRs). The Consultant Pharmacist also failed to provide correct dosage information of an antianxiety medication when communicating with the physician for a lowest effective dose evaluation for 1 of 5 residents reviewed for unnecessary medications (Residents #22). The findings included: Resident #22 was admitted to the facility on [DATE] with diagnoses including anxiety disorder. Review of the physician's orders dated 02/15/22 revealed Resident #22 had an order to receive 2 tablets of Buspirone 5 milligrams (mg) by mouth twice daily for generalized anxiety disorder. Review of medical records revealed the Consultant Pharmacist had conducted MRRs for Resident #22 in the past 10 months on 03/07/23, 04/03/23. 05/08/23,…

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 record review and interviews with resident, staff, Consultant Pharmacist, and the Medical Director (MD), the facility failed to implement a gradual dose reduction (GDR) for an antianxiety medication approved by the physician, resulting the resident to receive a higher dose of an antianxiety medication for over 9 months for 1 of 5 residents reviewed for unnecessary medications (Residents #22). The findings included: Resident #22 was admitted to the facility on [DATE] with diagnoses including anxiety disorder. Review of the physician's orders dated 02/15/22 revealed Resident #22 had an order to receive 2 tablets of Buspirone 5 milligrams (mg) by mouth twice daily for generalized anxiety disorder. Review of medical records revealed the Consultant Pharmacist had conducted medication regimen review (MRR) for Resident #22 in the past 10 months on 03/07/23, 04/03/23. 05/08/23, 06/05/23, 07/07/23, 08/02/23, 09/06/23, 10/06/23, 11/06/23, and 12/05/23. On 03/07/23, the Consultant Pharmacist recommended 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 and interviews, the facility failed to remove expired food from 1 of 3 kitchen refrigerators and clean and maintain 1 of 1 ice machine air filter vents (2). This practice had the potential to affect food and beverages served to residents. The findings included: An observation of the reach-in refrigerator in the kitchen on 12/18/23 at 8:34 AM found a 3.5-quart container labeled cheesecake dated 12/9/23. The container was located on the top shelf of the reach-in refrigerator and was half-full. An observation of the ice machine in the kitchen on 12/20/23 at 11:39 AM with the Dietary Manager revealed dirty air filter vents (2). Both air filter vents located directly above the door to the ice machine contained a build-up of brown and fluffy debris covering both air filter vents. The Dietary Manager (DM) was interviewed on 12/20/23 at 3:33 PM. The DM stated the cheesecake was left in the refrigerator and was overlooked by the dietary staff and should have been removed. The DM stated the ice machine air filter vents needed to be clean but was unsure whose…

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 and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions that the committee had previously put into place. This was for one repeat deficiency in the area of Food Procurement, Store/Prepare/Serve-Sanitary (F812) originally cited on 6/29/22 during a recertification and complaint investigation survey and subsequently cited on 12/22/23 during the recertification and complaint investigation survey. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program. This tag is cross referenced to: F812: Based on observations and interviews, the facility failed to remove expired food from 1 of 3 kitchen refrigerators and clean and maintain 1 of 1 ice machine air filter vents (2). This practice had the potential to affect food and beverages served to residents. During the recertification and complaint investigation survey of 6/29/22 the facility was cited for…

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 and staff interviews, the facility failed to protect private resident health information for 1 of 4 medication carts by leaving confidential medical information unattended and exposed in an area accessible to the public. (Medication cart #1 in East Hall) The findings included: 1.Resident #66 was admitted to the facility on [DATE]. A continuous observation was made on 12/18/23 from 8:16 AM through 8:18 AM for an unattended medication cart in East Hall. Nurse #2 left the medication cart with the computer screen open when she was in the nurse's station about 50 feet away. The computer screen showed the name, picture, and other private health information of Resident #66. The surveyor could access other residents' private health information easily through the computer. Nurse #2 returned to the medication cart 2 minutes later at 8:18 AM. During an interview conducted on 12/18/23 at 8:19 AM, Nurse #2 explained she was in the nurse's station putting away her winter jacket. She had forgotten to…

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 record review and staff interviews the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed for residents with new mental health diagnoses for 2 of 3 residents (Resident #64, #85) reviewed for PASRR. The findings include: 1. Review of Resident #64's medical record revealed the resident had a PASRR level I completed prior to admission dated 08/19/20 and was admitted to the facility on [DATE]. The resident was diagnosed with post-traumatic stress disorder (PTSD) on 06/15/23 and anxiety disorder on 06/15/23 as part of her admission. No PASRR level II had been completed per Resident #64 medical records. During a telephone interview on 12/20/23 at 11:15 AM with the previous Social Worker (SW) revealed she had been previously employed as the facility SW for the past 8 years and her last day of employment had been on 11/24/23. She stated during her employment as SW she had been responsible for completing PASRR upon a resident admission, when a change in condition or…

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, record review and interviews the facility failed to provide adaptive equipment for 1 of 1 resident reviewed for adaptive devices (Resident #26). Findings included: Resident #26 was admitted to the facility on [DATE] with diagnosis that included stroke affecting the right dominate side. A review of Resident #26's quarterly Minimum Data Set (MDS) dated [DATE] revealed moderate cognitive impairment and required set-up assistance with eating. Resident #26 was care-planned for potential malnutrition and dehydration related to a mechanically altered diet and hemiparesis. A listed approach for the care area was to provide adaptive equipment as ordered. The care plan was last revised on 10/5/23. A review of Resident #26's physician orders dated 10/17/23 and last reviewed on 12/5/23 for Mechanical soft diet with thin liquids and special instructions food to be put in a scoop dish for all meals, an adaptive cup at all meals and build up utensils for the left hand. An observation of the lunch meal…

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.