Stigler Nursing & Rehab

In the surveyor’s words

From the most serious findings on record at Stigler Nursing & Rehab, in the surveyor’s own words.

• Immediate jeopardy, patternF678Mar 1, 2023

  On [DATE] an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure staff were available 24 hours a day who had current certification in CPR for Healthcare Providers (training to include hands-on practice and in-person skills) and maintain their certifications to be able to provide CPR until emergency medical services arrived. The facility failed to have a CPR policy and ensure staff were familiar with facility policies related to CPR. Three of the facility's 15 nurses had CPR certification, one night shift nurse who worked three shifts a week, one weekend nurse, who worked the day shift, and the administrator/RN, who was not on the schedule. […]

• Immediate jeopardy, patternF689Mar 1, 2023

  On 02/28/23, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents who had fallen had interventions put in place to prevent the recurrence of falls; monitor and evaluate the effectiveness of the interventions; modify the care plan with each fall; conduct a root cause analyses for each fall; and communicate the interventions with all staff. Res #41 had 16 falls in four months with one fall resulting in a fractured hip. Res #41 had sustained a broken hip after six falls and only two falls had steps to prevent recurrence. Res #41 had nine falls after a hip fracture with only two of those falls having interventions to prevent recurrence. The last fall was 02/26/23. […]

• Immediate jeopardy, isolatedF689Aug 1, 2024

  On 07/31/24, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure Res #1, who was at risk for elopement, did not elope from the facility. Res #1 admitted to the facility on [DATE] with diagnoses including dementia. Res #1 eloped from the facility on 06/29/24 without staff knowledge and was returned to the facility by a community member. The facility did not complete one-on-one monitoring upon the Res #1's return or initiate environmental interventions for prevention. The care plan was not revised for the Res #1 and staff did not have a consistent plan to monitor and prevent elopement for the resident. […]

• Actual harm, patternF689May 17, 2021

  Based on observation, interview, and record review, it was determined the facility failed to ensure a resident received supervision and/or failed to implement and/or modify interventions to prevent [CONDITION(S)] from hot liquids for one (#27) of three residents who were reviewed for accident hazards. The resident received a second degree burn from spilling hot coffee onto her lap after interventions were not initiated to prevent [CONDITION(S)] from two previous incidents where the resident had spilled hot coffee onto her lap. The facility administrator (adm) identified three residents who were severely impaired with cognition and received their meals in their rooms. […]

• Actual harm, isolatedF600Feb 7, 2024

  Based on record review and interview, the facility failed to ensure a resident was free from abuse for one (#1) of four residents sampled for abuse. On 08/06/23 CNA #1 sprayed Res #1 in the face for five seconds while the resident was screaming, yelled at the resident, and then sprayed her in the face again again per witness statement and interview. CNA #1 was terminated for abuse on 08/06/23 and rehired on 09/21/23. The administrator identified 58 residents residing in the facility. Findings: A document titled, [NAME] County Nursing Center, dated 01/11/23, signed by CNA #1, read in part, .Abuse/Incident Reporting/Investigations What is reportable and actions to be taken: 1. Abuse is defined in many ways in the nursing home setting. […]