Stonecreek Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Stonecreek Health and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF656Aug 25, 2022

  Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure the Comprehensive Care Plan was implemented for one (1) of five (5) sampled residents (Resident #1). The facility assessed and care planned Resident #1 to require the assistance of two (2) staff members for bed mobility and incontinence care. However, on [DATE], Certified Nursing Assistant (CNA) #6 attempted to provide incontinence care without the assistance of another staff member as per the Comprehensive Care Plan (CCP). As a result, the resident sustained a fall from the bed, to the floor, hitting his/her head on a chair during the fall. Resident #1 was immediately transferred to the local hospital Emergency Department (ED). […]

• Immediate jeopardy, isolatedF689Aug 25, 2022

  Based on interview, record review, and facility policy review, it was determined the facility failed to ensure residents received adequate supervision to prevent accidents for one (1) of five (5) sampled residents (Resident #1). On admission to the facility on [DATE], the facility assessed Resident #1 as at risk for falls and the Comprehensive Care Plan (CCP) dated [DATE], revealed an intervention for the assistance of two (2) staff with bed mobility and incontinence care. However, on [DATE], Certified Nursing Assistant (CNA) #6 provided Resident #1's incontinence care while the resident was in bed without the assistance of another staff member as per the CCP, and the resident fell off the bed onto the floor. […]

• Actual harm, isolatedF656Feb 23, 2021

  Based on observation, interview, record review, and facility policy review, it was determined the facility failed to develop and implement a comprehensive person-centered care plan to meet two (2) of four (4) sampled residents' medical, nursing, mental, and psychosocial needs with services that were furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being (Residents #1 and #5). The facility readmitted Resident #5 from the hospital on 12/02/2020 with a Stage II pressure wound to his/her right buttock. […]

• Actual harm, isolatedF686Feb 23, 2021

  Based on observation, interview, record review, and review of facility's policy, it was determined the facility failed to provide care and services consistent with professional standards of practice to promote the prevention of pressure ulcer/injury development and the healing of existing pressure ulcers/injuries for two (2) of four (4) sampled residents (Residents #1 and #5). On 12/02/2020, the facility readmitted Resident #5 from the hospital with a Stage II pressure ulcer to his/her right buttock. The facility failed to document the description of wound characteristics (skin type and exudate), obtain a physician order to treat the pressure ulcer, complete a weekly skin assessment until 12/16/2020; and complete a weekly wound assessment until 12/19/2020. […]

• No harm, potential for more than minimal, widespreadF812Aug 1, 2024

  Based on observation, interview, review of facility policy, and review of the FDA Food Code 2022 the facility failed to thaw, store, label and date food in accordance with professional standards for food service safety. Observation revealed meat thawing in sinks, meat on a tray out at room temperature (temp). Additionally, observation revealed expired and/or outdated food in the walk in cooler. The findings include: 1. A policy on thawing of frozen foods was requested from the Dietary Manager on [DATE]; however, such policy was not received. Review of the FDA Food Code 2022 Chapter 3. […]