Stilwell Nursing and Rehab

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF803Aug 4, 2022

  Based on record review, observation, and interview, the facility failed to follow the menu provided for one meal of five meals reviewed for menu accuracy. The Resident Census and Conditions of Residents form documented 67 residents ate meals from the menu. Findings: A Menu: [NAME] SS 2022 documented the evening meal for Sunday, 07/31/22, was garden vegetable soup, deli sandwich on bun, potato chips, sugar cookies and beverage of choice. On 07/31/22 at 4:30 p.m. meal trays were observed to contain baked macaroni and cheese with ham, buttered peas, and frosted gelatin poke cake. On 08/01/22 at 12:05 p.m. the RD reported the menu for 07/31/22 evening meal wasn't followed and should have been.

• No harm, potential for more than minimal, patternF582Apr 9, 2025

  Based on record review and interview, the facility failed to ensure the estimated costs of services was included on form CMS-10055 (Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage) for 3 (#37, 78, and #79) of 3 sampled residents reviewed for beneficiary notifications reviews. MDS Coordinator #1 stated there had been 28 discharges from Part A services in the past six months (09/01/24 through 04/01/25). Findings: A facility policy titled, Medicare Advance Beneficiary and Medicare Non-Coverage Notices, dated September 2022, read in part, If the director of admissions or benefits coordinator believes (upon admission or during the resident's stay) that Medicare (Part A of the Fee for Service Medicare Program) will not pay for an otherwise covered skilled service(s), the… […]

• No harm, potential for more than minimal, patternF684Dec 14, 2023

  Based on record review and interview, the facility failed to follow physician's orders for a diabetic for one (#17) of one sampled resident whose record was reviewed for insulin usage. The DON identified 24 residents who required insulin. Findings: Res #17 was admitted with diagnoses which included diabetes. A physician order, dated 04/11/23, read in part, Novolog Solution, inject as per sliding scale .for glucose over 450, recheck in 1 hour, if glucose is still above 401 call physician . The TAR for October 2023 was reviewed with the following findings: On 10/02/23 at 8:00 p.m., Res #17's blood sugar was 468. No documentation blood sugar was rechecked an hour later. On 10/03/23 at 6:00 a.m., Res #17's blood sugar was 571. […]

• No harm, potential for more than minimal, patternF727Dec 14, 2023

  Based on record review and interview the facility failed to ensure the services of an RN was available in the facility eight hours daily seven days a week. The administrator identified 74 residents who resided in the facility. Findings: A document titled, Time Care Report, documented an RN was not present in the building on the dates of 09/16/23 and 09/17/23 for the month of September. A document titled Time Care Report documented an RN was not present in the building on the dates of 10/08/23 for the month of October. A document titled Time Care Report documented an RN was not present in the building on the dates of 11/18/23, 11/19/23, 11/25/23, and 11/26/23 for the month of November. […]

• No harm, potential for more than minimal, patternF804Dec 14, 2023

  Based on observation, record review, and interview, the facility failed to ensure food was palatable and at an appetizing temperature. The administrator identified 74 residents resided in the facility. Findings: 1. On 12/12/23 at 11:45 a.m., Res #24 stated they ate meals in their room. The resident stated the food was usually cold. On 12/12/23 at 9:03 a.m., Res #51 stated they ate in the dining room sometimes and sometimes in their room. The resident stated the food was always cold. 45913 2. On 12/13/23 at 1:24 p.m., a test tray was obtained as the last tray on Hall 6. The tray included black eyed peas with a temperature of 119 degrees; green beans at 111 degrees and did not taste seasoned; pork chop at 98 degrees which tasted lukewarm to cool; a roll at 109 degrees; and ice cream. […]