Stones River Manor, Inc

In the surveyor’s words

From the most serious findings on record at Stones River Manor, Inc, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812Jul 1, 2025

  Based on policy review, kitchen sanitation logs, refrigerator and dishwasher temperature logs, observation, and interview, the facility failed to ensure food was served under sanitary conditions when the kitchen floor was dirty with a black sticky substance, the deep fryer had thick sticky yellow dried coating on the outside, the steam table had dried brown streaks, the ice machine had a black dried substance on the inside, and undated items were in the refrigerator. The facility had a census of 27 with 26 of those residents receiving a tray from the kitchen. The findings include: 1. […]

• No harm, potential for more than minimal, isolatedF693Jul 1, 2025

  Based on policy review, medical record review, observation, and interview, the facility failed to ensure care and services were provided when a Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube inserted into the stomach to administer medications and food supplements through) dressing change was not completed as ordered for 1 of 1 (Resident #20) resident reviewed for the use of an enteral feeding.The findings include:1. Review of the facility policy titled, Gastrostomy/Jejunostomy Site Care, dated 2001, revealed .The purpose of this procedure are [is] to promote cleanliness and to protect the gastrostomy or jejunostomy site from irritation, breakdown and infection .Verify that there is a physician's order .gently clean the area immediately surrounding the tube .The person performing… […]

• No harm, potential for more than minimal, isolatedF880Jul 1, 2025

  Based on policy review, the facility's Infection Control documents, and interview, the facility failed to follow Infection Control practices when they failed to track pathogens (a bacteria, virus, or other microorganism that can cause disease) in the monthly .Infection Control 2025 report which could potentially affect 27 out of 27 Residents. The findings include: 1. Review of the facility's policy titled, Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, dated 12/2016, revealed .Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form.All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. […]

• No harm, potential for more than minimal, isolatedF609Sep 18, 2024

  483.12(c)(1) Based on facility policy review, Facility Reported Investigation (FRI) review, medical record review, and interview, the facility failed to report allegations of abuse within 2 hours for 1 (Resident #5) of 3 sampled residents reviewed for abuse. The findings included: Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating dated 4/2021 revealed, .All reports of resident abuse .Findings of all investigations are documented and reported .Reporting Allegations to the Administrator and Authorities . ' Immediately ' is defined as .a. within two hours of an allegation involving abuse . […]

• No harm, potential for more than minimal, isolatedF656Apr 6, 2023

  Based on facility policy review, review of the facility investigation, medical record review, and interview, the facility failed to develop and implement a person-centered care plan for 1 of 4 sampled residents (Resident #1) reviewed for care plans. The findings include: Review of the facility's policy, Care Plans, Comprehensive Person-Centered, revealed, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . Review of the facility investigation dated 1/1/2023, revealed Resident #1 reported a new female staff member who had been at the facility a few days told Resident #1 to shut up and quit telling her how to do her job. […]