Stillwater Creek Skilled Nursing and Therapy

In the surveyor’s words

From the most serious findings on record at Stillwater Creek Skilled Nursing and Therapy, in the surveyor’s own words.

• Actual harm, isolatedF689Oct 28, 2021

  Based on observation, interview and record review, it was determined the facility failed to provide supervision to prevent falls for one (#1) of three sampled residents reviewed for falls. This resulted in an actual harm to the resident. The DON identified 69 residents resided in the facility. Findings: Resident #1 had diagnoses which included, Alzheimer's disease. A quarterly resident assessment, dated 09/06/21, documented the resident's cognition was severely impaired, and was ambulatory without assistance. […]

• No harm, potential for more than minimal, patternF580Mar 15, 2024

  Based on record review and interview the facility failed to notify the physician when fingerstick blood sugar results were greater than 501 for one (#57) of one sampled resident reviewed for change in condition. The Administrator identified 66 residents resided in the facility. Findings: A Resident's Family or Physician Notification of Change Guideline policy dated 12/01/09, read in part .The facility will .consult with the resident's physician .of the following events .A need to alter treatment significantly. (i.e. […]

• No harm, potential for more than minimal, patternF686Mar 15, 2024

  Based on observation, record review, and interview, the facility failed to prevent development of new pressure ulcers for one (#15) of one sampled residents reviewed for pressure ulcers. Corporate consult RN #1 identified six residents resided in the facility with pressure ulcers. Findings: Res #15 had diagnoses which included quadriplegia, pressure induced deep tissue damage of left heel, and pressure ulcer of sacral region stage IV. A physician order, dated 02/12/24, documented heel lift boots in place every shift for wound prevention. A care plan, reviewed 02/13/24, documented Res #15 was to have heel lift boots in place every shift, and staff were to float heels with pillows while in bed. […]

• No harm, potential for more than minimal, patternF695Mar 15, 2024

  Based on observation, record review, and interview, the facility failed to obtain orders for continuous oxygen and failed to ensure oxygen tubing was changed and dated per physician orders for two (#1 and #9) of two sampled residents reviewed for oxygen administration. Corporate consult RN #1 identified 13 residents received oxygen in the facility. Findings: 1. Res #1 had diagnoses which included COPD. A physician order, dated 11/17/22, documented to administer oxygen at 2 liters per minute as needed to maintain oxygen saturation above 89%. A physician order, dated 11/17/22, documented to change oxygen tubing and humidifier bottle monthly on the 15th on night shift. The order documented to date tubing. A quarterly MDS, dated [DATE], documented Res #1 was cognitively intact. […]

• No harm, potential for more than minimal, patternF698Mar 15, 2024

  Based on record review and interview, the facility failed to ensure there was ongoing assessment of a resident on dialysis for one (#54) of one sampled resident reviewed for dialysis services. The administrator identified two residents received dialysis services. Findings: A Guidelines for Dialysis After Care policy and procedure, dated 07/11/12, read in part, .Inspection of the AVF .access and entire access extremity including hands or feet .Presence/absence or thrill and/or bruits .Signs and Symptoms of infection .Bruising and/or bleeding .Peripheral Pulses .Erosion of Skin or Sores over access site .Post dialysis dressing removal includes .Dressing should be removed 4 hours after dialysis treatment . Res #54 had diagnoses which included ESRD. […]