Stonehaven Health and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF726Feb 12, 2023

  Based on interviews, review of the Director of Nursing's (DON's) job description, and review of a facility policy titled, Competency Evaluation, Employee Identifier (EI) #2, the DON, failed to have a system in place to ensure nursing services personnel were competent and able to demonstrate timely and appropriate response, in accordance with facility policy, for Cardiopulmonary Resuscitation (CPR) in the event of residents becoming unresponsive and requiring CPR. On [DATE] at approximately 9:59 PM, EI #4, a Certified Nursing Assistant (CNA), found Resident Identifier (RI) #58 unresponsive and alerted the Licensed Practical Nurse (LPN), EI #3. […]

• Immediate jeopardy, isolatedF678Feb 12, 2023

  Based on record review, interviews, and review of a facility policy titled Cardiopulmonary Resuscitation (CPR), the Emergency Medical Services (EMS) run report, and the American Heart Association (AHA) Adult Basic Life Support (ABLS) Algorithm for Health Care Providers, the facility failed to ensure CPR response was provided in accordance with facility policy and in accordance with the AHA ABLS Algorithm for Health Care Providers for Resident Identifier (RI) #58 on [DATE], when Employee Identifier (EI) #4, a Certified Nursing Assistant (CNA), found RI #58 unresponsive and alerted the Licensed Practical Nurse (LPN), EI #3, around 9:59 PM. […]

• Actual harm, isolatedF656Jul 9, 2021

  Based on interviews, resident record review to include an Activity of Daily Living (ADL) care plan, review of a facility policy titled Care Plans - Comprehensive Person Centered Care Plans and a facility document titled CARE CARD INSTRUCTIONS, the facility failed to ensure Resident Identifier (RI) #8's ADL plan of care intervention for RI #8 to have assistance of two persons with Hoyer lift for all transfers, was implemented on 4/23/21 when RI #8 was transferred without the use of a Hoyer lift by Employee Identifier (EI) #4, Certified Nursing Assistant (CNA), EI #5 CNA, and EI #6 CNA. After transfer to the bed from the chair without the use of a Hoyer lift, RI #8's left ankle was swollen, warm to touch, and RI #8 complained of pain when touched. […]

• Actual harm, isolatedF689Jul 9, 2021

  Based on interviews, review of Resident Identifier (RI) #8's medical record, review of a facility policy titled Accidents and Incidents - Investigating and Reporting, and review of the facility's investigation file, the facility failed to ensure Employee Identifier (EI) #4, EI #5, and EI #6, Certified Nursing Assistants (CNAs), used a Hoyer lift to transfer RI #8 from chair to bed, as instructed by RI #8's plan of care, on 4/23/21 at 4:50 PM. EI #4, EI #5, and EI #6. After transfer to the bed from the chair without the use of a Hoyer lift, RI #8's left ankle was swollen, warm to touch, and RI #8 complained of pain when touched. […]

• No harm, potential for more than minimal, widespreadF812Feb 12, 2023

  Based on observations, interviews and review of the 2017 Food Code, the facility failed to ensure: 1. two ovens were not found with a heavy build-up of what appeared to be food crumbs in the bottoms and in the crevice between the oven floor and the oven door; 2. a heavy amount of a grease-like build-up was not observed on eight of ten stove top grates; and 3. pots were not stacked on a shelf with crumbs and dust. This had the potential to affect all 52 residents who received meals from the kitchen. Findings Include: The 2017 Food Code of the U.S. (United States) Public Health Service and the FDA (Food and Drug Administration) included the following: . 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. . […]