Stone Oak Care Center

Inspectors wroteBased on observation, interview, and record review, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for one (1) of six (6) residents (Resident #1) reviewed for medical records. The facility failed to include documentation to show Resident #1 and/or Resident #1's family member agreed to the resident residing in the locked unit. This failure could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records.

Inspectors wroteBased on interview, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable, physical, mental, and psychosocial well-being for 1 of 1 nurse (LVN A) reviewed for competent nursing care. The facility failed to ensure the LVN A practiced nursing within her scope of practice when she conducted an initial admission assessment, initiated a baseline care plane and initiated the comprehensive care plan for Resident #1. This deficient practice affects residents who depend on nursing care and could place residents at risk for incomplete or inaccurate assessment and care plans.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident and determined that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for 1 of 4 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure Resident #1's Lantus (insulin glargine- a long-acting insulin) was administered on 11/28/2025. This failure could place the residents at risk of hyperglycemia (elevated blood glucose levels) and poorly controlled diabetes.

Inspectors wroteBased on interview and record review the facility failed to ensure medical records were maintained in accordance with accepted professional standards and practices for each resident, that were complete and accurately documented for 1 of 4 residents (Residents #1) reviewed for accuracy of medical records. The facility failed to ensure Resident #1's progress notes were documented accurately and according to professional standards of practice when LVN A documented she administered Lantus (insulin glargine-a long-acting insulin) on 11/28/2025 when she did not. This deficient practice could place residents at risk for errors in care and treatment and inaccuracies in documentation.

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives through effective communication for 1 of 2 residents (Resident #1) reviewed for hospice services. The facility failed to collaborate with hospice upon Resident #1 admission on [DATE] to ensure the resident received three glaucoma medications she was taking at home and were detailed on her preadmission home health pre-admission paperwork. This deficient practice could place residents who receive hospice services at risk of receiving inadequate care due to a lack coordination of care, and communication of resident needs and could lead in complications of eyesight.

Inspectors wroteBased on interviews and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #1) of 5 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #1 was coded on his Quarterly MDS assessment, signed as completed on 11/03/2025, for a fall without injury that occurred on 10/07/2025. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.

Inspectors wroteased on interview and record review, the facility failed to have evidence that all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for 2 of 8 residents (Resident # 2 and Resident # 6) reviewed for abuse and neglect. The facility did not provide evidence of a thorough investigation, including interviews with residents in the unit where Resident #2 resided, following a family member's allegation of neglect to the Admin on 8/7/2025. The facility did not provide evidence of a thorough investigation, including interviews with residents in the unit where Resident #6 resided, following a family member's allegation of abuse to the Admin. on 8/1/2025. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of 1 of 5 residents (Resident #4) reviewed for pharmacy services. The facility failed to ensure Resident #4's PRN Tramadol (a pain medication) orders included the necessary indications for administration. These failures could lead to mismanagement of a resident's pain or unintended sedation.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records on each resident, in accordance with accepted professional health information management standards and practices, that are: complete, and accurately documented for 1 (Resident #3) of 15 residents reviewed for clinical records, in that:Resident #3's clinical record contained inaccurate information. This deficient practice could cause miscommunication among the resident's caregivers and result in improper care.

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 1 of 2 residents (Resident #4) reviewed for infection control. The facility failed to properly implement enhanced barrier precautions for Resident #4. This failure could result in the spread of infection or illness.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for three residents (Residents #2, #11 and #14) of thirty-two residents reviewed for MDS assessments. The Facility failed to note on Resident #2's admission MDS dated [DATE] he was taking a hypoglycemic medication. 2. The facility failed to ensure Resident #11's Quarterly MDS assessment was coded Not rated, resident had a catheter instead of Always incontinent for a resident identified to have a suprapubic catheter. 3. The facility failed to ensure Resident #14's quarterly MDS assessment was coded Yes regarding the resident was receiving antidepressant for his depression. These failures could place resident at risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #98) of 28 residents, 1 of 1 medication rooms, and 1 (500-hall nursing cart) of 5 med carts reviewed for pharmacy services. 1. There were three antibiotic solutions (Imipenem and cilastatin) for Resident #98 to be given via intravenous route that expired 07/22/2025 found inside the facility medication room on 07/24/2025. 2. There was one super sani-cloth germicide disposable wipe that expired 05/2025 found inside the facility medication room on 07/24/2025. 3. There was one bottle of Senna-Plus 8.6 mg that expired 06/2025 found inside the 500-hall nurse cart on 07/24/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. 1. The facility failed to store plastic cups and bowls to allow for air-drying in the dish room.2. The facility failed to ensure all prepared items in the walk-in refrigerator was labeled and dated with use by date. These failures could place residents at risk for food borne illness. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. 1. The facility failed to store wet insulated plastic dome plate covers to allow for air-drying by the steam table.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 (Resident #32) of twenty-eight residents reviewed for environment, in that: Resident #32's room air conditioning vents were visibly soiled. This deficient practice could result in residents living in an unclean and unpleasant environment.

Inspectors wroteBased on interviews and record reviews, the facility failed to encode and transmit required MDS information within 14 days after discharge for 2 of 32 residents reviewed for MDSs.1. Resident #24 was discharged on 01/29/25 and as of 07/24/25 he did not have a discharge MDS assessment. 2. Resident #84 was discharged on 03/14/25 and as of 07/24/25 did not have a discharge MDS assessment. This deficient practice affects residents who receive care at the facility and could result in negative impacts on discharge planning.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 (Residents #20 and #64) of ten residents reviewed for incontinence care. 1. When CNA-A and CNA-B were providing peri care to Resident #20, CNA-A cleaned the resident's genital area without separating the labia. 2. When CNA-C and CNA-D were providing peri care to Resident #64, CNA-C did not clean the resident's suprapubic area (below the umbilical region), left groin area, and left buttock area and cleaned the resident's genital area with multiple passes with one wipe. This failure could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs for 2 of 10 residents (Residents #20 and #64) by 2 of 4 CNAs (CNA-A and CNA-C) reviewed for competent staff, in that: 1. When CNA-A was providing peri care to Resident #20, CNA-A cleaned the resident's genital area without separating the labia. 2. When CNA-C was providing peri care to Resident #64, CNA-C did not clean the resident's suprapubic area (below the umbilical region), left groin area, and left buttock area and cleaned the resident's genital area with multiple passes with one wipe. The failure could place residents at risk for not receiving nursing services by adequately trained staff and could result in a decline in health and infection. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 (Resident #64) of twenty-eight residents reviewed for infection control practices. When CNA-C was providing peri care to Resident #64, CNA-C changed gloves without sanitizing or washing his hands. This deficient practice could place residents at risk for cross contamination and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure Resident #1 did not elope from the facility without staff knowing from 05/10/25 at 06:03 PM to 05/11/25 at 12:50 AM (approximately 6 hours and 47 minutes). The noncompliance was identified as PNC. The IJ began on 05/10/25 and ended on 05/11/25. The facility had corrected the noncompliance before the investigation began. This deficient practice could place residents at-risk of harm, serious injury, or death.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse, to the administrator of the facility and to other officials including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities in accordance with State law through established procedures for 2 of 4 residents (Residents #2 and #3), reviewed for freedom from abuse, neglect, and exploitation. The facility failed to report the incident of suspected abuse on 6/5/25 when the visitor was noted pounding hard on the bed of Resident # 2 , yelling WAKE UP! . [...]

Inspectors wroteBased on interviews, and record reviews the facility failed to have evidence all allegations of abuse, neglect or mistreatment were thoroughly investigated and documented for 1 of 5 residents (Resident #2) reviewed for abuse. The facility failed to have evidence that a thorough investigation was conducted following the allegation Resident #2 was yelled at and had her bed pounded by a visitor. These failures could place residents at risk for abuse and neglect by not investigating allegations of abuse, neglect, exploitation, or mistreatment.

Inspectors wroteBased on interviews and record reviews the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible, and were systematically organized, for 2 of 5 residents (Residents #4 and #5) reviewed for consents for accurate medical records. 1. The facility failed to document a discharge summary in Resident #4's electronic medical record on 01/24/25, when Resident #4 discharged . 2. The facility failed to document shower/bath for Resident #5 appropriately on 06/02/25. These failures could place residents at risk for inaccurate and unorganized medical records.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 1 resident (Resident #55) of 24 residents reviewed for MDS assessments. The facility failed to ensure Resident #55's quarterly MDS, dated [DATE], accurately reflected she does not have a feeding tube. This deficient practice could place residents at [NAME] of inadequate care.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 (Resident #16, and #58) of 24 residents reviewed for care plans. 1. Facility failed to develop and implement a person-centered care plan for Resident #16 to reflect she took an anticonvulsant medication daily. 2. Facility failed to develop and implement a person-centered care plan for Resident #16 to accurately reflect she was not on oxygen therapy. These deficient practices could places residents at risk of not receiving required specific care, services and interventions.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 (Resident #58) of 2 residents observed for gastrostomy tube (tube surgically placed through the abdomen to the stomach for feeding and medications) feeding and medication administration via the tube. The facility failed to ensure Resident #58's enteral feeding tube rate was set at 65cc's per hour as the physician ordered and medication flushes were not provided between medication administration as ordered. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive care plan, the resident's goals and preferences for 1 (Resident #16) of 3 residents observed on oxygen therapy. The facility failed to ensure Resident #16's oxygen was set at 2L/min as prescribed This deficient practice affects residents on oxygen therapy and could place them at risk for respiratory distress.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure that nurses were able to demonstrate competency in skills and techniques to provide nursing and related services for 1 of 2 residents (Resident #58 ) by 1 of 2 nurses (LVN C) reviewed for competent staff, in that: LVN C failed to provide G-tube flushes before medications administration and between medication administration as ordered for Resident #58. These failures could place residents at risk for not receiving nursing services by adequately trained and licensed nurses and could result in a decline in health.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. CNA B picked up a resident's roll that had fallen off his tray onto the table with her bare hands and placed the roll onto the resident's dish at lunchtime. This deficient practice could affect residents who dine in the dining room and place them at risk for contamination of food.

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 disease and infection for 2 of 8 residents (Residents #41 and #58) reviewed for infection control, in that: 1. CNA B did not change gloves and sanitize or wash her hands before touching Resident #41's clean brief during incontinent care. 2. LVN C did not wear gloves to touch Resident #58's medication. These failures could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on observation, interview , and record review, the facility failed to assist residents in obtaining routine dental services to meet the needs of 1 of 11 residents (Resident #27) reviewed for dental services, in that: The facility did not assist Resident #27 with obtaining dental services when her bottom dentures were reported missing. This failure could place residents at risk of not having their oral health care needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: There was a tray of cheese sandwiches in the walk-in refrigerator without a use by date and beyond the 72 hours discard date. This failure could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs of 3 of 8 residents (Residents #59, Resident #87, and Resident #93) reviewed for accommodation of needs. The facility failed to place Residents #59's, Resident #87's, and Resident #93's call-lights within reach. This failure could place residents at risk of not being able to obtain assistance as needed.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and assistance devices to prevent accidents for 1 of 2 Residents (Resident #84) whose records were reviewed for falls. 1. Nursing staff failed to ensure Resident #84 wore non-skid socks when not wearing shoes. 2. Nursing staff failed to propel Resident #84 forward and safely while in his wheelchair. 3. A sharps (razor) was left on top of the vanity in Resident #84's restroom for 2 days; to ensure the water temperature did not exceed 110 degrees and that the aerator did not spray water out when the faucet was turned on. These deficient practices could affect residents at risk for falling, who used a wheelchair for mobility, and residents who wandered and could contribute to avoidable accidents.

Inspectors wroteBased on observations, interviews, and record reviews, 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 2 of 12 residents (#41 and #84) reviewed for infection control practices, in that: 1. The door and door handle to Resident #41's room was visibly soiled with a brown sticky substance. 2. There were two handheld urinals (with visible yellow liquid in the urinals) hung on the safety bar in Resident #84's restroom for two days. The urinals were not secured in a plastic bag, labeled or dated per facility policy. These failures could place residents at risk related to the spread of communicable diseases and infections.

Inspectors wroteBased on observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 6 Resident (Resident #84) who was observed for dignity. Nursing staff was propelling Resident #84 backwards and preventing him from propelling forward freely in his wheelchair. This failure could affect any resident and contribute to feelings of frustration and dissatisfaction.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's right to formulate an advance directive for 2 of 8 residents (Residents #50 and #74) reviewed for advanced directives. 1. Resident #50's OOH-DNR was invalid as it was not completed per requirements. 2. The facility failed to ensure Resident #74's OOH-DNR was completed correctly. These failures could place residents at risk of not having their end of life wishes followed and could result in CPR being performed against their wishes.

Inspectors wroteBased on interview and record review, the facility failed conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity within 14 days calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition for 1 of 8 residents (Resident #76) reviewed for Comprehensive Assessments and timing. The facility failed to ensure an MDS Assessment for Resident #76 was completed within 14 days after admission. This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to refer all residents with newly evident or possible serious mental disorder for PASARR level II evaluation upon a significant change in status assessment for 2 of 5 residents (Resident #84 and Resident #81) whose PASARR records were reviewed. 1. MDS staff failed to submit a level II PASARR evaluation for over 6 months after Resident #84 was diagnosed with unspecified Psychosis. 2. Resident #81 did not have a PASRR level II evaluation with diagnoses of bipolar disorder, and schizoaffective disorder, bipolar type. These failures could place residents at risk for not receiving the specialized PASARR care and services required to meet their individual needs and could result in a decrease in quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet residents' mental, nursing, and mental and psychosocial needs for 1 of 8 residents (Resident #76) reviewed for care plans, in that: The facility failed to develop and implement a comprehensive person-centered care plan for Resident #76 within the required time frame. This failure could affect residents who have care areas not addressed by the care plan by not having their needs met and putting them at risk of not receiving appropriate care.

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 2 of 3 (Resident #33 and #76) reviewed for hospice services. 1. The facility failed to obtain Resident #33's most recent hospice plan of care, signed hospice election form, and a physician's re-certification of the terminal illness. 2. The facility failed to obtain Resident #76's most recent hospice plan of care, signed hospice election form, and documentation by specific interdisciplinary hospice staff providing services. [...]