Stone Oak Care Center

In the surveyor’s words

From the most serious findings on record at Stone Oak Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 27, 2025

  Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure Resident #1 did not elope from the facility without staff knowing from 05/10/25 at 06:03 PM to 05/11/25 at 12:50 AM (approximately 6 hours and 47 minutes). The noncompliance was identified as PNC. The IJ began on 05/10/25 and ended on 05/11/25. The facility had corrected the noncompliance before the investigation began. This deficient practice could place residents at-risk of harm, serious injury, or death. […]

• Actual harm, isolatedF689Feb 12, 2023

  Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free from accident hazards as was possible and that each resident received adequate supervision to prevent accidents for 2 of 26 residents (Residents #1 and #2) reviewed for accidents/supervision in that: 1. The facility failed to ensure the safety and prevent serious bodily injury of Resident #1 by failing to provide the adequate supervision necessary to prevent Resident #2 from wandering into Resident #1's room. This failure could place residents at risk of harm or injury and contribute to avoidable accidents. The findings were: 1. […]

• No harm, potential for more than minimal, widespreadF812Apr 28, 2023

  Based 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 for 1 of 1 kitchen, in that: There was a tray of cheese sandwiches in the walk-in refrigerator without a use by date and beyond the 72 hours discard date. This failure could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings were: An observation and interview with the Food Service Supervisor on 04/25/2023 at 11:40 a.m., revealed a tray with cheese sandwiches, prepped for residents who would request a grilled sandwich, in the walk-in refrigerator. […]

• No harm, potential for more than minimal, patternF641Jul 25, 2025

  Based on observations, interview and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for three residents (Residents #2, #11 and #14) of thirty-two residents reviewed for MDS assessments. The Facility failed to note on Resident #2's admission MDS dated [DATE] he was taking a hypoglycemic medication. 2. The facility failed to ensure Resident #11's Quarterly MDS assessment was coded Not rated, resident had a catheter instead of Always incontinent for a resident identified to have a suprapubic catheter. 3. The facility failed to ensure Resident #14's quarterly MDS assessment was coded Yes regarding the resident was receiving antidepressant for his depression. […]

• No harm, potential for more than minimal, patternF755Jul 25, 2025

  Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #98) of 28 residents, 1 of 1 medication rooms, and 1 (500-hall nursing cart) of 5 med carts reviewed for pharmacy services. 1. There were three antibiotic solutions (Imipenem and cilastatin) for Resident #98 to be given via intravenous route that expired 07/22/2025 found inside the facility medication room on 07/24/2025. 2. There was one super sani-cloth germicide disposable wipe that expired 05/2025 found inside the facility medication room on 07/24/2025. 3. […]