Stonecreek Nursing & Rehabilitation

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain all essential equipment in safe operating condition, for 1 of 1 stove reviewed for food service in that:The facility did not ensure the gas stove was in working order. One of four gas stove burners (right front) did not light properly when the knob was turned. This failure could place residents who eat out of the kitchen at risk of injury and undercooked food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program for one of one kitchen reviewed for pest control. The facility failed to ensure an effective pest control program was in place to keep mice out of the kitchen. This failure could place residents at risk of food borne illness and exposure to pests.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards and each resident received adequate supervision as is possible for 3 of 15 residents (Resident's #2, #16, and #17) reviewed for accidents and hazards.1. The facility failed to ensure that Resident #2 did not have a rechargeable vape device secured to his finger with a hair tie and tape while in bed on 3/30/26.2. The facility failed to ensure that Resident #16 had a safe smoking assessment prior to being allowed to keep electronic vape devices at bedside on 3/30/26.3. The facility failed to ensure that Resident #17 did not use an electronic vape device in her room on 3/30/26. These failures could place residents at risk of secondhand exposure, nicotine overdose and vape related injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 2 medication carts (nurse cart for Hall C/D) reviewed for labeling and storage. The facility did not document when insulin was opened from the nurse medication cart for Hall C/D.These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications, decreased quality of life, and hospitalization.

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 in the facility's only kitchen reviewed for food safety requirements and kitchen sanitation 1. The facility failed to ensure foods stored in the freezer were labeled, dated, and sealed. 2. The facility failed to ensure dented cans were separated from non-dented cans. These failures could place residents at risk of foodborne illness and food contamination.

Inspectors wroteBased on observations, interviews, 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 6 residents (Resident #16, Resident #26, and Resident #20) and 3 of 5 staff (CNA A, CNA C, and CNA D) reviewed for infection control. The facility failed to ensure CNA A washed or sanitized her hands when passing out meal trays to residents on Hall B on 2/3/2025. CNA A did not sanitize or wash her hands between glove changes when incontinent care was provided to Resident #16 on 2/4/2025. The facility failed to ensure a Yaunker suction tip (an oral suctioning tool) for Resident #20 was not left open and uncovered on a bedside table. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs and describes the services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 2 of 12 residents (Residents #16 and Resident #34) reviewed for care plans in that: The facility failed to develop a comprehensive care plan for the use of side rails for Resident #16 that were in use on 2/4/2025. The facility failed to develop a comprehensive care plan for the use of side rails for Resident #34 that were in use on 2/3/25. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail, assess the resident for risk of entrapment from bed rails prior to installation for 2 of 5 residents (Resident #16 and Resident #34) reviewed for bed rails. The facility failed to obtain an order or complete an assessment for the use of bedrails for Resident #16 who had full bed rails on both sides of her bed on 2/4/2025. The facility failed to obtain an order or complete an assessment for the use of assist rail for Resident #34 who had a ½ rail in place to the left side of his bed on 2/3/25. These failures could place residents at risk of entrapment or injury.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in locked compartments and permit only authorized personnel to have access to the keys for 1 of 6 residents (Resident #50) reviewed for medication storage. The facility did not ensure Caladryl lotion was not stored at the bedside for Resident #50 on [DATE]. This failure could place all residents at risk of misuse of medication and decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable State laws for 2 of 16 licensed nursing staff (ADON and RN A) reviewed for staff qualifications. 1. The facility failed to ensure the ADON's nursing license was not expired between [DATE] and [DATE]. 2. The facility failed to ensure RN A's nursing license did not expire as of [DATE]. These failures could place residents at risk for not receiving nursing services by a licensed nurse.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from abuse for 1 of 3 residents (Resident #1) reviewed for abuse. The facility failed to prevent CNA A, on 9/04/24, from abusing Resident #1 when she purposefully tossed water on her. The noncompliance was identified as PNC. The noncompliance began on 09/04/24 and ended on 09/04/24. The facility had corrected the noncompliance before the survey began. The failure could place residents at risk for emotional distress, fear, decreased quality of life and further abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen. The facility did not label or date a bag of unknown substance in the freezer, whipped topping, and diced peppers, did not dispose of cheesecake, lettuce, chicken wings and shrimp, and did not cover drinks stored in walk in cooler. These failures could place residents at risk for food-borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to ensure the drug regimen review recommendations from the pharmacy consultant were acted upon for 7 of 16 residents (Residents #209, #40, #308, #10, #6, #44 and #208) reviewed for drug regimen review. -The Facility did not follow up on the pharmacy consultant's recommendations for Gradual Dose Reduction (GDR) dated 01/11/2023 for Resident #209, #40 and #308 until 05/03/2023, four months after original recommendation. -The Facility did not follow up on the pharmacy consultant's recommendations for Gradual Dose Reduction (GDR) dated 05/10/2023 and 05/11/2023 for Resident #10, #6, #44 and #208 until 07/10/2023 and 07/11/2023, two months after original recommendation. -The Facility did not develop policies and procedures to address the timeframes of the medication regimen review (MRR). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 1 of 4 halls (D hall) reviewed for palatable food. The facility failed to provide palatable food served at an appetizing temperature on 1/24/2024 to residents on D hall for the breakfast meal. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to be equipped to allow residents to call for staff through a communication system which relays the call directly to a centralized staff work area for 2 of 5 residents reviewed for call lights. (Resident #41 & #49). The facility failed to ensure Resident #41 and #49's emergency call light in the bathroom would reach the floor. The call light cords were gathered and secured with a rubber band. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to review and revise the person-centered care plan to reflect the current condition for 1 of 5 residents (Resident #33) reviewed for care plans. The facility failed to ensure Resident #33's care plan reflected current resident code status within 7 days of the resident assessment. This failure could place residents at risk of not receiving appropriate care to meet their current needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in a form designed to meet the needs for 1 of 6 residents (Resident #27) reviewed. The facility failed to ensure that Resident #27 received nectar thickened liquids as ordered. These failures could place residents at risk for aspiration.

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 1 of 6 residents (Resident # 28) reviewed for infection control. CNA A failed to perform proper hand hygiene while providing incontinent care to Resident #28 on 01/23/2024. This failure 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 the right to be free from misappropriation of property was provided for 2 of 5 residents reviewed for misappropriation of property. (Resident #3 and Resident#4). The facility failed to prevent a diversion (misappropriation ) of Resident #3's methocarbamol tablets (used to treat muscle spasms and pain) a total of 60 tablets in two blister packs filled 5/23/23. One blister pack of the two packs dated 5/23/23 was observed in custody at the Sheriff's department containing 22 of 30 tablets and Resident #4's bottle of amoxicillin capsules (used to treat infection) was observed in custody at the Sherriff's department on 11/15/23, after being turned in by complainant. This failure could place residents at risk for decreased quality of life, misappropriation of property, and dignity.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident or legal representatives right to participate in the development and implementation of his or her person-centered plan of care, for 1 of 5 Residents (Resident #1) reviewed for care plans. The facility did not include the correct representatives for Resident #1 (representative D and representative E) in the initial plan meeting on 9/21/23 to discuss Resident #1's care . This failure could cause residents or representatives to not be able to participate in the planning of their care, not receiving the care they want or need, and not being informed of all services offered by the facility.