Stone Cottage Care Center

Inspectors wroteBased on observation, record review, resident and staff interviews, the facility failed to maintain the dignity for one of three residents reviewed (Resident #8) when they failed to ensure to keep him from sitting in his own stool for hours before staff provided incontinence cares and failed to treat him with dignity and respect by using profanity. The facility reported a census of 35 residents.

Inspectors wroteBased on observation, record review, resident and staff interview, the facility failed to provide oral cares to one of three residents reviewed (Resident #6) and failed to provide peri cares for one of three residents reviewed (Resident #8). The facility reported a census of 35 residents.

Inspectors wroteBased on clinical record review, facility policy review, and staff and resident interviews, the facility failed to separate 2 residents (Resident's #11 and #12) from one another after one of the residents made verbal threats that she would hit the resident, and subsequently observed behind the resident with her arm raised in the air as if to strike the resident. As a result of the failure to separate the residents, Resident #11 was able to strike Resident #12 in the head in the dining room during the breakfast meal, at a time when staff were in the area and could have taken action to prevent it. Resident #12 sustained a bruise on her face and requested transfer to another facility. The facility reported a census of 35 residents.

Inspectors wroteBased on observation, record review, resident and staff interview, the facility failed to answer call lights timely for two of three residents reviewed (Residents #6 reported he had to wait at least 30 minutes to get his call light answered 3 to 4 times a week and Resident #8 reported to has to wait over an hour to get his call light answered on a daily basis). The facility reported a census of 35 residents.

Inspectors wroteBased on clinical record review, staff and resident interview the facility failed to provide occupational therapy for one ofone residents reviewed for occupational therapy services. (Resident#8). The facility reported a resident census of 35.

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review. The facility failed to provide 2 of 2 residents (Resident #2 and Resident #5) reviewed for accommodation of needs, with an effective call light system to meet the needs of residents who have both upper and lower extremity impairments. The facility reported a census of 32 residents.

Inspectors wroteBased on observations, staff and resident interview, clinical record review, and facility policy review the facility failed to answer resident call lights in a timely manner for 1 of 3 residents (Resident #2) reviewed for call lights, when the resident reported waiting for assistance took greater than 15 minutes. The facility reported a census of 32 residents.

Inspectors wroteBased on observation, clinical record review, and staff and resident responsible party interviews, the facility failed to provide adequate supervision and staff assistance to residents to prevent injuries from falls, for 1 of 4 residents with fall histories reviewed (Resident #4). The facility's failure to provide the appropriate supervision and assistance resulted in Resident #4's hospitalization in a hospital Intensive Care Unit with injuries that included hemothorax, fractured 6th through 10th right ribs, displaced right shoulder and compression fracture of the 10th thoracic vertebrae that resulted from an unwitnessed fall. The facility reported a census of 34 residents.

Inspectors wroteBased on professional certification review and staff interviews, the facility failed to employ a qualified person to serve as the Dietary Manager in the absence of a full-time dietitian. The facility reported a census of 30 residents.

Inspectors wroteBased on review of Quality Assurance and Performance Improvement(QAPI) meeting documentation, policy review, and staff interview, the facility failed to maintain documentation that the facility carried out Quality Assurance(QA) activities to develop, implement and evaluate corrective actions or performance improvement activities and take action to conduct structured, systematic investigations, analysis of underlying causes or contributing factors of problems affecting facility-wide processes that impact quality of care, quality of life, and resident safety. The facility reported a census of 30 residents.

Inspectors wroteBased on record review, resident interviews, resident council minutes, staff interviews, and policy review the facility failed to provide sufficient nursing staff to ensure resident needs were met in a timely manner. During the survey 4 of 5 residents reviewed for call lights (Residents #6, #8, #11, #12) reported waiting as long as 90 minutes for call lights to be answered. The facility reported a census of 30 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and staff interviews, the facility failed to interact with a resident in a respectful manner for 1 of 3 residents reviewed for dignity(Resident #26). The facility reported a census of 30 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and staff interivew, the facility failed to ensure a resident rinsed their mouth in accordance with professional standards for 1 of 1 residents reviewed for the administration of an inhaler(Resident #26). The faciltiy reported a census of 30 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and staff interview, the facility failed to notify the physician of a resident's refusal of an ordered diet and failed to carry out specialized Speech Therapy(ST) services for a diagnoses of dysphagia(difficulty swallowing) for 1 of 2 residents reviewed for a change in condition(Resident #10). The facility reported a census of 30 residents.

Inspectors wroteBased on record review, resident interviews, staff interviews, and the facility policy, the facility failed to adequately supervise a resident after they went outside without oxygen for 1 of 1 residents reviewed for elopement (Resident #22). The facility reported a census of 30 residents.

Inspectors wroteBased on record review, staff interviews, and the facility policy, the facility failed to verify oxygen orders with the hospice provider for 1 of 1 residents reviewed oxygen therapy orders (Resident #22). The facility reported a census of 30 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and staff interview, the facility failed to ensure the medication error rate did not exceed 5%. The facility's medication error rate calculated as 7%. The facility reported a census of 30 residents.

Inspectors wroteBased on record review, staff interviews, and the facility policy, the facility failed to administer a resident their prescribed controlled medication for 1 of 6 residents reviewed for medication administration (Resident #17). The facility reported a census of 30 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interview, the facility failed to offer a Covid-19 booster to 1 of 5 residents reviewed for immunizations(Resident #3) and failed to provide information to staff regarding the Covid-19 vaccination.

Inspectors wroteBased on clinical record review, staff and resident interviews, the facility failed to ensure a resident's right of choice and self determination regarding their health care needs for 1 of 3 residents reviewed. (Resident #1) The facility reported census was 26.

Inspectors wroteBased on clinical record review, staff and family interview, the facility failed to ensure that the transfer or discharge met all documentation requirements necessary for a safe and effective transition of care for one of four residents reviewed. (Resident #1) The facility reported census was 25.

Inspectors wroteBased on clinical record review, staff and family interview, the facility failed to provide adequate notice of discharge in writing and proper contents of notice, including a statement of the resident's appeal rights prior to discharge for one of four. (Resident #1) The facility reported census was 25.

Inspectors wroteBased on document review, policy review, and staff interviews, the facility failed to employ a qualified person to serve as the Director of Food and Nutrition Services in the absence of a full-time dietitian. The facility reported a census of 22 residents.

Inspectors wroteBased on observation, policy review, and staff interview, the facility failed to maintain adequate sanitation for 2 of 2 kitchen observations and failed to carry out sanitary food handling during 1 of 1 meal service observation. The facility reported a census of 22 residents.

Inspectors wroteBased on employee file review, policy review and staff interviews, the facility failed to conduct a record check evaluation prior to employment to indicate clearance for work for 1 of 5 employee files reviewed. The facility reported a census of 22 residents.

Inspectors wroteBased on clinical record review, staff interview, and policy review the facility failed to include fall interventions for 1 of 2 residents reviewed with a history of falls (Resident #21), failed to address nutrition needs for 1 of 2 residents reviewed for weight loss (Resident #21), and failed to address a resident's history of sexual behaviors toward other residents/staff for 1 of 2 residents reviewed for resident-to-resident interactions (Resident #12). The facility reported a census of 22 residents.

Inspectors wroteBased on observation, record review, staff interview, and the facility policy, the facility failed to ensure an insulin vial discarded after it was opened past 28 days for 1 of 1 residents reviewed for insulin administration (Resident #5). The facility reported a census of 22 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interviews, the facility failed to recognize and address weight fluctuations for a resident at risk of impaired nutrition for 1 of 2 residents reviewed for weight loss(Resident #21). The facility reported a census of 22 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and staff and resident interviews, the facility failed to ensure a resident's oxygen tank was available for use for 1 of 1 residents reviewed receiving oxygen therapy (Resident #3). The facility reported a census of 22 residents.

Inspectors wroteBased on clinical record review, policy review, and resident and staff interviews, the facility failed to ensure that 1 of 1 resident reviewed for pain (Resident #15) received treatment and care related to pain management. The facility reported a census of 22 residents.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to screen residents for eligibility and/or failed to document refusals for the pneumococcal vaccines for 3 of 5 residents reviewed. (Resident #5, Resident #7, and Resident #12). The facility reported a census of 22 residents.

Inspectors wroteBased on record review, staff interview, and facility policy review the facility failed to screen residents for eligibility of the COVID-19 vaccines and/or failed to document refusal or acceptance of the COVID-19 vaccines for three of five residents reviewed. (Resident #5, Resident #7, and Resident #12) ) The facility reported a census of 22 residents.

Inspectors wroteBased on staff interview, review of CMS-2567 reports, and facility QAPI (Quality Assurance and Performance Improvement) Plan, the facility failed to ensure an effective QAPI (Quality Assurance Performance Improvement) process to address previously identified quality deficiencies, resulting in multiple repeat deficiencies identified on the facility's current recertification and complaint survey previously identified during surveys completed in the last 17 months. The facility reported a census of 22 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and staff and resident interviews, the facility failed to treat residents with dignity and respect by failing to assist a resident with positioning in a dignified manner (Resident #1), failing to avoid roughness during incontinence cares (Resident #5), failing to speak to residents in a dignified manner and ensure confidentiality (Resident #5), and failing to engage with residents during the provision of cares (Resident #9) for 3 of 11 residents reviewed for dignity. The facility reported a census of 23 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and staff and resident interviews, the facility failed to protect a resident (Resident #4) from being pinched by another resident (Resident #1) on 4/17/24 with a history of physical aggression for 1 of 1 residents reviewed for abuse. The facility reported a census of 23 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and staff and resident interviews, the facility failed to report an allegation of abuse to the State Agency when a staff member failed to treat a resident with dignity and respect during positioning (Resident #1) for 1 of 2 residents reviewed for an allegation of abuse. The facility reported a census of 23 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and staff and resident interviews the facility failed to complete a thorough investigation and ensure immediate protection for 2 of 2 residents reviewed for an allegation of abuse (Resident #1) from a staff member and for an allegation of abuse from a fellow resident (Resident #3). The facility reported a census of 23 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and staff and resident interviews, the facility failed to adequately supervise a resident (Resident #3) in order to protect another resident's personal privacy (Resident #1) for 2 of 5 residents reviewed for supervision. The facility reported a census of 23 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and staff and resident interviews, the facility failed to provide sufficient staff with skill sets to care for a cognitively impaired resident who required 1:1 supervision (Resident #1) and a resident with behaviors affecting others (Resident #3). The facility reported a census of 23 residents.

Inspectors wroteBased on record review, policy review, and staff interview, the facility failed to carry out quality assurance (QA) activities in order to address problem-prone areas and create a plan for improvement. The facility reported a census of 23 residents.

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to maintain sufficient nursing staff to enable relief for scheduled nurses upon completion of their 12 hour shift, 4 times between 1/9/24 and 1/22/24, that required the nurse on duty to work in excess of 24 consecutive hours on 2 of the 4 dates, and the facility could not identify a plan for the future that would provide 100 percent certainty that the scheduled nurse on duty would have relief after their completed shift, if the scheduled relief staff failed to come to work. The facility reported a census of 27 residents.

Inspectors wroteBased on record review, and staff interviews, the facility failed to provide the required 8 consecutive hours of Registered Nurse (RN) coverage on 4 dates between 1/10/24 and 1/25/24. The facility reported a census of 27 residents.

Inspectors wroteBased on record review and staff interviews, the facility failed to follow directives as ordered and mandated in Level II PASRR assessments, and failed to submit a new PASRR assessment when a 90 day conditional Level II PASRR expired, for 2 of 2 resident's reviewed with Level II PASRR's (Resident's #1 and #4). The facility reported a census of 27 residents.

Inspectors wroteBased on record review, facility policy, and staff and resident responsible party interviews, the facility failed to develop a person-centered care plan that addressed specific safety needs of a resident, for 1 of 5 resident records reviewed (Resident #1). The facility reported a census of 27 residents.

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to follow physician orders for wound care, and failed to ensure documentation was accurate and not falsified, for 1 of 5 resident records reviewed (Resident #3). The facility reported a census of 27 residents.

Inspectors wroteBased on record review, and staff and resident responsible party interviews, the facility failed to provide adequate supervision to promote resident safety and prevent a resident to resident incident that resulted in an injury, for 2 of 5 resident records reviewed (Resident's #1 and #2). The facility reported a census of 27 residents.

Inspectors wroteBased on staff interviews, resident interviews, and record review the facility failed to have sufficient Registered Nurse (RN) coverage at least 8 consecutive hours a day for 8 of 37 days reviewed. The facility reported a census of 28 residents.

Inspectors wroteBased on observation, interviews, and policy review the facility failed to maintain equipment and to prepare foods under sanitary conditions for 3 of 3 kitchen observations. The facility failed to repair the sanitizing triple sink, the Handwashing sink, and the cooking sink in a timely manner. The facility reported a census of 28 residents.

Inspectors wroteBased on Resident Council documentation, resident interviews, and staff interviews the facility failed to thoroughly act on grievances voiced in resident council for 2 of 2 months reviewed. The facility reported a census of 28 residents.

Inspectors wroteBased on observation, record review, resident interview, and staff interview the facility failed to provide ready access to personal funds managed by the facility for 1 of 3 residents reviewed (Resident #3) and failed to provide quarterly statements for 11 of 11 residents reviewed. The facility reported a census of 28 residents.

Inspectors wroteBased on observation, resident interviews, staff interviews, and policy review the facility failed to maintain a clean, safe environment with scheduled cleaning identified by visible carpet stains made by urine, blood, and feces which left noticeable odors in a resident room, the North hall, and a common television area near the dining room. The facility reported a census of 28 residents.

Inspectors wroteBased on observation, interviews, and record review the facility failed to provide sufficient nursing staff to meet the acuity needs of the facility's resident population for 3 of 5 residents reviewed (Residents #1, #2, and #3). The facility reported a census of 28. 1. The Quarterly Minimum Data Set (MDS) for Resident #1 dated 10/26/23 documented diagnoses of cerebral palsy, quadriplegia, and disruptive mood dysregulation disorder. MDS Section C documented an inability to complete the Brief Interview for Mental Status (BIMS), indicative of severely impaired cognition. Section GG indicated the resident was always incontinent; dependent for toilet, tub, and chair transfers; and needed substantial/maximal assistance with toileting, bathing, and dressing. A Care Plan intervention initiated 12/20/23 indicated a poor awareness of personal care and health needs. [...]

Inspectors wroteBased on observation, interviews, record review, and policy review the facility failed to complete an assessment for 1 of 4 (Resident #5) residents who smoked. The facility reported a census of 28.

Inspectors wroteBased on resident interview, staff interview, record review, facility investigation review and facility policy review the facility failed to report an allegation of abuse for 1 of 3 residents reviewed for abuse. The facility staff failed to report an allegation of abuse that occurred on 11/10/23 which alleged staff member pushed and threatened Resident #3. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of November 10, 2023 on November 27, 2023 at 3:45 PM. The facility staff removed the Immediate Jeopardy on November 28, 2023 at 3:10 PM by implementing the following actions: a. Licensed Practical Nurse (LPN) Staff A was suspended on 11/20/23 b. All staff education began on 11/27/23 by the Administrator c. [...]

Inspectors wroteBased on resident interview, staff interview, record review, facility investigation review, and facility policy review the facility failed to treat 1 of 3 residents reviewed with dignity. (Resident #3). The facility reported a census of 28.

Inspectors wroteBased on observation, staff interview, resident/family interview and record review the facility failed to ensure safe transport of resident in a wheelchair for 1 of 3 residents reviewed. (Resident #2). The facility reported a census of 28.

Inspectors wroteBased on clinical record review and staff interviews, the facility failed to ensure residents receive adequate supervision and assistance devices to prevent accidents. (Resident #2) The facility reported census was 26.

Inspectors wroteBased on observations, resident and staff interviews, record review and policy review, the facility failed to treat residents with divinity and respect for 5 of 5 residents reviewed (Residents #2, #5, #11, #18 & #24). The facility reported a census of 22 residents.

Inspectors wroteBased on resident and staff interviews, record review and policy review, the facility failed to report suspicion of verbal abuse and neglect affecting the psychosocial well being for 4 of 4 residents reviewed (Resident #5, #11, #18, #24). The facility reported a census of 22 residents.

Inspectors wroteBased on resident and staff interviews, record review and policy review, the facility failed to take action to investigate alleged violation of abuse to prevent further neglect and mistreatment of 4 of 4 residents reviewed (Resident #5, #11, #18, #24). The facility reported a census of 22 residents.

Inspectors wroteBased on observation, record review, policy review, and staff interview, the facility failed to store and prepare foods under sanitary conditions for 2 of 2 kitchen observations. The facility reported a census of 22 residents.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure timely assessment and submission of veteran status (state law requirement) for 4 of 5 residents (Residents #6, #20, #24, and #176). The facility reported a census of 22 residents.

Inspectors wroteBased on Quality Assurance(QA) signature sheets, policy review, and staff interview, the facility failed to ensure it held quarterly QA meetings throughout the survey year. The facility reported a census of 22 residents.

Inspectors wroteBased on Quality Assurance(QA) signature sheets, policy review, and staff interview, the facility failed to ensure it held quarterly QA meetings throughout the survey year. The facility reported a census of 22 residents. Findings Include: The facility policy QAPI(Quality Assurance and Performance Improvement) Plan, dated 1/1/23, stated the committee would meet regularly to discus Performance Improvement Plans (PIPs) and progress. A QA Meeting Signature Sheet listed attendees of a QA meeting on 3/15/23. The facility lacked documentation of additional QA meetings held during the survey year from 4/7/22-6/26/23. In email correspondence, sent on 6/27/23 at 1:02 p.m., the Administrator documented he could not locate additional QA documentation. On 6/29/23 at 12:42 p.m., the Administrator stated the facility should conduct QA meetings quarterly.

Inspectors wroteBased on clinical record review, policy review, and staff interview, the facility failed to document the reason for discharge from skilled services, the date of notification of Medicare Non-Coverage, and/or appeal decisions for 3 of 3 residents reviewed for completed Medicare services (Residents #176, #177, and #178). The facility reported a census of 22 residents.

Inspectors wroteBased on observation, clinical record review, policy review, resident interview, and staff interview, the facility failed to carry out a root cause analysis and implement care plan interventions in order to prevent falls for 1 of 1 residents reviewed for falls(Resident #2). The facility reported a census of 22 residents.

Inspectors wroteBased on observation, clinical record review, policy review, resident interview, and staff interview, the facility failed to carry out a root cause analysis and implement interventions in order to prevent falls for 1 of 1 residents reviewed for falls(Resident #2). The facility reported a census of 22 residents.

Inspectors wroteBased on observation and staff interview, the facility failed to complete and post daily staffing that included name, date, census, number of staff, and hours worked for licensed and non-licensed staff. The facility reported a census of 22.

Inspectors wroteBased on clinical record review, policy review, and staff interview, the facility failed to document attempts of non-pharmacological interventions prior to the administration of as needed (PRN) psychotropic medications for 1 of 1 residents reviewed for prn psychotropic medications(Resident #13). The facility reported a census of 22 residents.