Stallings Court Nursing and Rehabilitation

Inspectors wroteBased on observation, interview and record reviews, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection and new pressure ulcers from developing for 1 of 3 (Resident #1) residents reviewed for pressure injuries.1. The facility did not ensure Resident #1's interventions were in place with heel protectors and keep heels floating while in bed on 5/27/2026.2. The facility failed to ensure Resident #1 did not develop a pressure-related deep tissue injury on 4/23/2026. These failures could place residents at risk for new development or worsening of existing pressure injuries, pain, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #5) and of 1 of 2 staff (CNA A) reviewed for infection control. The facility failed to ensure CNA A performed hand hygiene between glove changes and that she changed gloves when going from dirty area to clean area on 2/19/26 during perineal care for Resident #5. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 3 of 17 residents reviewed for quality of care. (Resident #19, Resident #38, and Resident #40)The facility failed to remove worn and damaged mechanical lift slings from service for Resident's #19, #38, and #40. This failure could result in a loss of quality of life due to injuries.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure the temperature for the dish machine was at the appropriate temperature of 120 degrees Fahrenheit during the wash cycle according to the manufacturer's guidelines to sanitize dishes appropriately on 02/04/2026. This failure could place residents who eat from the kitchen at risk of foodborne illnesses.

Inspectors wroteBased on interview and record review the facility failed to make sure a comprehensive care plan was prepared by an interdisciplinary team, that included but not limited to a nurse aide with responsibility for the resident and a member of food and nutrition services staff for 4 of 4 residents (Residents #6, #27, #54 and #58) reviewed for care plans. The facility failed to ensure the dietary manager and nurse aides with responsibility for the residents were invited and attended the resident care plan conferences. This failure could place residents at risk for not receiving the care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good, nutrition, grooming and personal and oral hygiene for 4 of 12 residents (Residents #34, #37, #48, #69) reviewed for activities of daily living . 1. The facility failed to ensure Resident #37's had clean linens on 11/19/2024. 2. The facility failed to provide nail and mouth care to Resident #34 on 11/18/24 and 11/19/2024. 3. The facility failed to provide nail care to Resident #48 on 11/18/24 and 11/19/24. 4. The facility failed to ensure Resident #69 did not have oily hair and body odor on 11/18/24. These failures could place residents at risk of not having their needs met which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure drugs and biologicals were store in locked compartments under proper temperature controls for 2 of 3 medication carts (medication aide cart and nurse cart for halls 300 and 400), 1 of 1 medication rooms and 1 of 16 residents (Resident #18) reviewed for pharmacy services. The facility failed to ensure Fluticasone nasal spray was properly stored and locked in accordance with currently accepted professional standards for Resident #18 from 11/18/2024-11/19/2024 that was at her bedside. 1. The facility failed to dispose of expired medications from the medication aide and nurse medication carts on 11/19/2024 which included: (3) packages of Juven nutrition powder with use by date of November 1, 2024. (2) bottles of Glucerna 1.2 cal dated November 1, 2024. 2. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident was provided food prepared in a form designed to meet individual needs for 3 of 3 residents (Residents #27, Resident #12 and Resident # 24) reviewed for pureed diets. The facility failed to prepare the pureed diet to the consistency required for Resident #27, Resident #12 and Resident #24. This failure could place residents at risk of not having nutritional needs met by consuming foods that could cause choking and decreased meal intakes.

Inspectors wroteBased on an interview and record review the facility failed to maintain a Quality Assessment and Assurance Committee which consisted at a minimum of the director of nursing services, the Medical Director or designee, at three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role and the infection preventionist and the facility failed to ensure the Quality assessment and assurance committee met quarterly and as needed to coordinate and evaluate activities, including performance improvement projects required under QAPI program for 4 of 11 months (April 2024, May 2024, July 2024 and October 2024. reviewed for QAA/QAPI. 1. The facility failed to ensure the Medical Director attended their QAA and QAPI meetings for the months of April 2024, May 2024 and July 2024. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 10 residents (Residents #11, #65, and #181) and 2 of 6 staff (CNA C and CNA H) reviewed for infection control. 1. CNA C failed to change gloves and perform hand hygiene during incontinent care for Resident #11 on 11/18/2024. 2. The facility failed to ensure CNA C did not enter the isolation rooms of Residents #65 and #181 without PPE on 11/18/24. These failures could place residents at risk of exposure to infectious diseases .

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or quality of life, recognizing each resident's individuality for 1 of 6 residents (Resident # 11) observed for resident rights. CNA C and the ADON failed to provide Resident #11 with full privacy while receiving care on 11/18/2024. This failure could place residents at risk of not being treated with dignity and respect.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrably unavoidable for 1 of 6 residents (Resident #14) reviewed for quality of care. The facility failed to ensure Resident #14 had her splints for contractures in her hands on 11/18/24. This failure could place residents at risk of increased contractures, not receiving care and services to maintain their highest level of well-being and decline.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and service to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #76) reviewed for indwelling catheter. The facility failed to ensure Resident #76's indwelling catheter securement device was in place. This failure could place residents at risk for urethral tears, discomfort, infection and hospitalization.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 2 of 16 residents (Resident #3 and Resident #4) reviewed for accidents/hazards. The facility failed to remove worn and damaged mechanical lift slings from service. This deficient practice could place residents at risk of a loss of quality of life due to injuries.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program for 14 of 14 employees (Administrator, DON, ADON, FSS, AD, LVN G, RN H, LVN J, DOR, CNA K, CNA L, CNA M, CNA N, and CNA D) reviewed for training, in that: The facility failed to ensure that quality assurance and performance improvement training was provided to the Administrator, DON, ADON, FSS, AD, LVN G, RN H, LVN J, DOR, CNA K, CNA L, CNA M, CNA N, and CNA D. This failure could place staff and residents at risk for not being aware of facility programs, implementation, and monitoring.

Inspectors wroteBased on interview and record review, the facility failed to provide the required compliance and ethics training for 14 of 14 employees (Administrator, DON, ADON, FSS, AD, LVN G, RN H, LVN J, DOR, CNA K, CNA L, CNA M, CNA N, and CNA D) reviewed for training, in that: The facility failed to ensure compliance and ethics training was provided to the Administrator, DON, ADON, FSS, AD, LVN G, RN H, LVN J, DOR, CNA K, CNA L, CNA M, CNA N, and CNA D. This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 1 of 5 residents (Resident #69) and 2 of 5 (medication cart for halls 300 and 400 and nurse medication cart for halls 100 and 200) reviewed for pharmacy services. The facility did not ensure medications were properly administered to Resident #69. The facility failed to remove a bottle of levothyroxine (thyroid medication) 50 mcg tablets that expired on 6/14/2023 for Resident #52 from the medication cart for halls 300 and 400. The facility failed to remove 4 bottles of Glucerna 1.5 Cal with a used by date of September 1, 2023 from the medication cart for halls 100 and 200. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 8 staff (MA E and LVN F) and 4 of 7 residents (Resident #8, Resident #18, Resident #58, and Resident #45) reviewed for infection control in that: MA E did not clean the blood pressure cuff between residents (Resident #8, #18, #58) and she did not wash or sanitize her hands in between any of the residents (Resident #8, #58, #18 and #45) observed during medication administration . LVN F did not wash or sanitize her hand in between glove changes while checking the blood sugar of Resident #45. These failures could place residents at risk of exposure to communicable diseases and infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident was treated with respect, dignity, and care for 1 of 6 residents (Resident # 224) observed for care in that: CNA D failed to sit while feeding Resident #224 in his room. This failure could affect residents in the facility who received care and could result in residents not being treated with dignity and respect.

Inspectors wroteBased on interview and record review the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change of condition for 1 of 6 Residents (Resident #6) reviewed for PASSAR (Preadmission Screening and Resident Review Services) in that: Resident #6 did not have a PASSR level II evaluation with diagnosis of psychotic disorder(abnormal thinking and perceptions) and major depressive disorder(persistent feeling of sadness or loss of interest). The MDS Coordinator failed to refer Resident #6 for a resident review after being diagnosed with major depressive disorder on 1/23/2023 and psychotic disorder on 5/16/2023. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #13) reviewed for care plans in that: The facility failed to implement a comprehensive person-centered care plan for Resident #13 addressing PTSD. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs.

Inspectors wroteBased on interviews and record review, the facility failed to implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 1 of 5 residents (Resident #55) reviewed for care plans. The facility failed to ensure Resident #55's care plan was updated to indicate her gastrostomy tube status. This failure could place the resident at increased risk of not having their individual needs met and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the drug regimen review recommendation from the pharmacy consultant were acted upon for 1 of 4 residents reviewed for drug regimen review. (Resident #31) -The facility did not follow up on the pharmacy consultant's recommendations for Gradual Dose Reduction dated 8/21/32 with the physician for Resident #31 until 10/03/23 to decrease Doxepin 6mg to Doxepin 3mg at bedtime. -The facility did not develop policies and procedures to address the timelines of the MRR. These failures could place residents being at risk for medication errors, unnecessary medications, and incorrect administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 8 residents personal refrigerators reviewed for food safety (Resident #18). The facility failed to ensure the refrigerator for Resident #18 did not contain an unlabeled, undated, or expired yogurt and cottage cheese. This failure could place residents at risk for food borne illnesses.