Standing Stone Care And Rehab

Based on observation, interview, and facility policy review, the facility failed to ensure 1 of 2 medication carts observed was free of loose pills. Findings include: A facility policy titled, Storage of Medication, dated 01/2025, indicated, Policy - Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. The policy also indicated, 16. Medication storage areas should be kept clean, well lit, organized and free of clutter. An observation of the medication cart at Nursing Station 2, on 05/13/2026 at 10:38 AM, revealed in the second drawer, under the medication bubble-pack cards, there was one loose round, yellow-colored pill and one loose oval, peach-colored pill. The observation revealed in the medication cart's third drawer, under the medication bubble-pack cards, there was one loose, round, white-colored pill. During a concurrent interview, the Infection Preventionist (IP) stated that the loose pills should not have been in the medication cart. The IP…

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 facility policy review, medical record review, and interview, the facility failed to resubmit a Pre-admission Screening and Resident Review (PASRR) to include an active mental health condition present upon admission for 1 resident (Resident #22) of 4 residents reviewed for PASRR. The findings include: Review of the facility's policy titled, Pre-admission Screening and Resident Review (PASRR), revised 9/15/2023, revealed .PASARR is a federal requirement .be evaluated for serious mental illness .A negative Level I screen permits admission .and ends the PASARR process unless a possible serious mental disorder arises later .Referral should be made as soon as the criteria indicating such are evident . Review of a PASRR Level 1 screen outcome for Resident #22 dated 10/28/2024, revealed the resident did not have mental health conditions diagnosed or suspected. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including Dementia, Post Traumatic Stress…

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 facility policy review, medical record review, and interview, the facility failed to develop a comprehensive person-centered care plan related to Post Traumatic-Stress Disorder (PTSD) for 1 resident (Resident #25) of 2 residents reviewed for PTSD. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, revised 2/9/2024, revealed .The facility will develop and implement a comprehensive person-centered care plan for each resident .to meet resident's .mental and psychosocial needs that are identified in the comprehensive assessment . Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder, Anxiety Disorder, and PTSD. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #25 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment and the resident had an active diagnosis of PTSD.…

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 facility policy review, medical record review, observation, and interview, the facility failed to label a tube feeding formula appropriately for 1 resident (Resident #80) of 1 resident sampled for tube feeding. The findings include: Review of the facility's policy titled, Gastrostomy [tube placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications] Feeding Guidelines, revised 2/7/2023, revealed .Label bag with tube-feeding type, strength, and amount .include date, time, and initials . Review of the medical record revealed Resident #80 was admitted to the facility on [DATE] with diagnoses including Protein-Calorie Malnutrition, Dysphagia (difficulty swallowing), and Gastrostomy. Review of a Physician's Order for Resident #80 dated 2/12/2025, revealed .Enteral Feed .[name of tube feeding formula] at 40 ml/hr [milliliters per hour] . Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #80 scored a 13 on 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 facility policy review, facility investigation documentation review, medical record review, observations, and interviews the facility failed to protect the residents' right to be free from physical abuse by another resident for 8 residents (Residents #5, #6, #7, #8, #10, #11, #14, and #15) of 14 residents reviewed for abuse. The findings include: Review of the facility policy titled, Abuse, Neglect and Misappropriation of Property, revised [DATE], revealed .organizations intention to prevent the occurrence of abuse .all alleged Abuse, Neglect, exploitation, injuries of unknown origin, and Misappropriation of resident property is investigated .are reported immediately .Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish . 1. On [DATE], Resident #6 placed hands on Resident #5's chest and pushed Resident #5 backward in wheelchair. Review of the facility investigation dated [DATE], revealed an altercation…

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 facility policy review, medical record review, facility investigation review, and interview, the facility's direct care staff failed to immediately report allegations of staff on resident abuse which resulted in a delay of reporting abuse to the State Designated Authority for 1 resident (Resident #3) of 14 residents reviewed for abuse. The facility was cited at F-609 at a scope and severity of D as past noncompliance. Noncompliance began on 5/13/2024 and ended on 5/21/2024. The facility is not required to submit a Plan of Correction for F-609. The findings include: Review of the facility policy titled, Abuse, Neglect and Misappropriation of Property, dated 9/15/2023, revealed .Every Stakeholder shall immediately report any allegations of abuse .All such persons are encouraged to follow these reporting guidelines when they have reason to believe, that abuse, neglect, exploitation is occurring, has occurred, or plausibly may have occurred .Any abuse allegation must be reported to State within 2 hours 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.

Based on facility policy review and interview, the facility failed to implement an Antibiotic Stewardship program for 67 of 67 residents residing in the facility. The findings include: Review of facility policy Antibiotic Stewardship dated 11/7/18 revealed .The organization has developed an antibiotic stewardship program that will facilitate the responsible use of antibiotics, improve resident safety, reduce healthcare costs and potentially impact rates of antibiotic resistance. Our Antibiotic Stewardship Program (ASP) will promote the appropriate use of antibiotics for the correct indication, dose, and duration; and monitor resident outcomes including adverse events . Telephone interview with the Medical Director on 9/24/19 at 10:19 AM revealed he was not aware of an Antibiotic Stewardship Program at the facility. Interview with the Director of Nursing (DON) on 9/24/19 at 10:30 AM, in the Administrator's office, revealed the facility was unable to provide documentation of an Antibiotic Stewardship Program. Telephone interview with the Consulting Pharmacist on 9/24/19 at 11:03 AM…

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 review of facility policy, review of a facility investigation, medical record review, and interviews, the facility failed to report an allegation of abuse timely to the State Survey Agency for 1 resident (#23) of 3 residents reviewed for abuse. The findings include: Review of facility policy Abuse, Neglect and Misappropriation of Property, last revised 5/8/19, revealed .It is the organization's intentions to prevent the occurrence of abuse .Any abuse allegation must be reported to State within 2 hours from the time the allegation was received . Review of a facility investigation dated 9/3/19 revealed an unidentified resident reported an allegation of abuse involving Resident #23. Further review revealed .heard [Resident #23] yelling out saying 'stop that' .'that hurts' .[named Certified Nurse Assistant (CNA) #1] was 'being a smart mouth' .assuming [CNA #1] pinched her b/c [because] she [Resident #23] never yells . Continued review revealed no documentation the allegation was reported to the State Survey…

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 review of facility policy, review of a facility investigation, medical record review, review of employee time sheets, and interview, the facility failed to suspend an employee during an investigation of an allegation of abuse for 1 resident (#23) of 3 residents reviewed for abuse. The findings include: Review of the facility policy Abuse, Neglect and Misappropriation of Property, last revised 5/8/19 revealed .It is the organization's intentions to prevent the occurrence of abuse .If .suspected .perpetrator is a Stakeholder, the charge nurse immediately will remove that stakeholder from resident care areas and suspend him/her while the matter is investigated . Review of a facility investigation dated 9/3/19 revealed an unidentified resident reported an allegation of abuse involving Resident #23. Further review revealed .heard [Resident #23] yelling out saying 'stop that' .'that hurts' .[named Certified Nurse Assistant (CNA) #1] was 'being a smart mouth' .assuming [CNA #1] pinched her b/c [because] she…

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.