Stuart Rehabilitation and Healthcare

In the surveyor’s words

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

• No harm, potential for more than minimal, isolatedF684Apr 11, 2025

  Based on record review and interview, it was determined, the facility failed to appropriately assess 1 of 2 sampled residents experiencing changes in condition, Resident #1, as evidenced by the lack of monitoring signs and symptoms of a bowel obstruction, that included vomiting, diarrhea, bradycardia / tachycardia and fever. The findings included: Clinical record review conducted on 04/10/25 revealed Resident #1 has been a long-term care resident at the facility since 08/29/22. […]

• No harm, potential for more than minimal, isolatedF655May 23, 2024

  Based on record review and staff interview, the facility failed to implement a baseline care plan within 48 hours of admission for 2 of 17 newly admitted sampled residents, Resident #202 and Resident #71. The findings included: 1. Record review documented Resident #71 was admitted to the facility on [DATE] with diagnoses which included Parkinsonism, Obstructive and Reflux Uropathy, Alzheimer's Disease, and Dementia. A review of Resident #71's electronic health record (EHR) contained no evidence of a Baseline Care Plan completed within 48 hours of Resident #71's admission. 2. […]

• No harm, potential for more than minimal, isolatedF657May 23, 2024

  Based on record review and interview, the facility failed to ensure residents were invited to participate in care plan meetings for 1 of 19 sampled residents reviewed, Resident #61. The findings included: On 05/20/24 at 12:50 PM, and interview was conducted with Resident #61, The resident was asked if she attends her care plan meetings. She stated she didn't know what I was talking about and had never been to a care plan meeting. Review of Resident #61's medical records revealed the resident was admitted to the facility on [DATE]. A review of her quarterly MDS (Minimum Data Set) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating an intact cognition. […]

• No harm, potential for more than minimal, isolatedF695May 23, 2024

  Based on observation, record review, interview, and policy review, the facility failed to ensure respiratory care and services for 3 of 3 sampled residents, as evidenced by staff failed to store and change oxygen and nebulizer (a device for administering a medication by spraying a fine mist) tubing for Resident #36; failed to remain with Resident #36 during a nebulizer treatment, then failed to complete a post treatment assessment as per policy; failed to assess Resident #306 before and after a nebulizer treatment; and failed to obtain a physician order for oxygen use for Resident #9. […]

• No harm, potential for more than minimal, isolatedF761May 23, 2024

  Based on observation, record review, interview, and policy review, the facility failed to ensure accurate labeling of medications for 2 of 8 sampled residents, Resident #5 and #9, who had medication ordered for bedtime, with a change in scheduled administration time, and failed to identify the change on the medication packaging. The findings included: Review of the policy, titled, Medication Ordering and Receiving from Pharmacy, dated May 2022 documented, in part, Policy: Medication are labeled in accordance with facility requirements and state and federal laws. Only the dispensing pharmacy / registered pharmacist can modify, change, or attach prescription labels. Procedures: . G. Medication labels are not altered, modified, or marked in any way by nursing personnel. […]