Stonecreek Health and Rehabilitation

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased on record review, and staff, Medical Director, and Orthopedic Surgeon interviews, the facility failed to complete and document assessments of a surgical site. Resident #63 had an unwitnessed fall on 11/28/24 and suffered a fracture in the epicondyle region (bony prominence on the humerus bone in the arm) of the elbow. Resident #63's on 12/13/24 the resident underwent an open reduction internal fixation (ORIF) surgical procedure (involves making an incision to realign the bone and then holding the pieces together with hardware like plates, screws, or rods). At Resident #63's follow-up appointment with the Orthopedic Surgeon on 12/26/24 Occupational Therapy (OT) for range of motion (ROM), pain and edema (swelling caused by a buildup of fluid) control, home exercise program (HEP), and splint wear with removal for hygiene purposes and active ROM exercises was ordered. [...]

Inspectors wroteBased on record review, and staff, Medical Director, and Orthopedic Surgeon interviews, the facility failed to communicate to the therapy department an Occupational Therapy (OT) referral ordered by Resident #63's Orthopedic Surgeon for evaluation and treatment of the resident's right olecranon (tip of the elbow). On 12/13/24 the resident underwent an open reduction internal fixation (ORIF) surgical procedure (involves making an incision to realign the bone and then holding the pieces together with hardware like plates, screws, or rods). At Resident #63's follow-up appointment with the Orthopedic Surgeon on 12/26/24 he ordered OT for range of motion (ROM), pain and edema (swelling caused by a buildup of fluid) control, home exercise program (HEP), and splint wear with removal for hygiene purposes and active ROM exercises. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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)

Inspectors wroteBased 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.

Inspectors wroteBased on observations, record review and interviews the facility failed to provide adaptive equipment for 1 of 1 resident reviewed for adaptive devices (Resident #26).