Standing Stone Care and Rehab

In the surveyor’s words

From the most serious findings on record at Standing Stone Care and Rehab, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF761May 14, 2026

  Based on observation, interview, and facility policy review, the facility failed to ensure 1 of 2 medication carts observed was free of loose pills. Findings include: A facility policy titled, Storage of Medication, dated 01/2025, indicated, Policy - Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. The policy also indicated, 16. Medication storage areas should be kept clean, well lit, organized and free of clutter. […]

• No harm, potential for more than minimal, isolatedF644Mar 4, 2025

  Based on facility policy review, medical record review, and interview, the facility failed to resubmit a Pre-Admission Screening and Resident Review (PASRR) to include an active mental health condition present upon admission for 1 resident (Resident #22) of 4 residents reviewed for PASRR. The findings include: Review of the facility's policy titled, Pre-Admission Screening and Resident Review (PASRR), revised 9/15/2023, revealed .PASARR is a federal requirement .be evaluated for serious mental illness .A negative Level I screen permits admission .and ends the PASARR process unless a possible serious mental disorder arises later .Referral should be made as soon as the criteria indicating such are evident . […]

• No harm, potential for more than minimal, isolatedF656Mar 4, 2025

  Based on facility policy review, medical record review, and interview, the facility failed to develop a comprehensive person-centered care plan related to Post Traumatic-Stress Disorder (PTSD) for 1 resident (Resident #25) of 2 residents reviewed for PTSD. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, revised 2/9/2024, revealed .The facility will develop and implement a comprehensive person-centered care plan for each resident .to meet resident's .mental and psychosocial needs that are identified in the comprehensive assessment . Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder, Anxiety Disorder, and PTSD. […]

• No harm, potential for more than minimal, isolatedF693Mar 4, 2025

  Based on facility policy review, medical record review, observation, and interview, the facility failed to label a tube feeding formula appropriately for 1 resident (Resident #80) of 1 resident sampled for tube feeding. The findings include: Review of the facility's policy titled, Gastrostomy [tube placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications] Feeding Guidelines, revised 2/7/2023, revealed .Label bag with tube-feeding type, strength, and amount .include date, time, and initials . Review of the medical record revealed Resident #80 was admitted to the facility on [DATE] with diagnoses including Protein-Calorie Malnutrition, Dysphagia (difficulty swallowing), and Gastrostomy. […]

• No harm, potential for more than minimal, isolatedF600Jan 15, 2025

  Based on facility policy review, facility investigation documentation review, medical record review, observations, and interviews the facility failed to protect the residents' right to be free from physical abuse by another resident for 8 residents (Residents #5, #6, #7, #8, #10, #11, #14, and #15) of 14 residents reviewed for abuse. The findings include: Review of the facility policy titled, Abuse, Neglect and Misappropriation of Property, revised [DATE], revealed .organizations intention to prevent the occurrence of abuse .all alleged Abuse, Neglect, exploitation, injuries of unknown origin, and Misappropriation of resident property is investigated .are reported immediately .Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting… […]