Studebaker Healthcare Center

In the surveyor’s words

From the most serious findings on record at Studebaker Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 20, 2024

  Based on observation, interview and record review, the facility failed to ensure a resident, who was at a moderate risk for elopement, did not elope from the facility for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure licensed nurses assessed Resident 1 to determine his risk for wandering and elopement upon admission to the facility (12/28/2023). 2. Ensure a care plan was developed with interventions to prevent Resident 1 from further attempts to leave the facility immediately following Resident 1's attempt to leave the facility on 1/12/2024. 3. […]

• Actual harm, isolatedF689Jul 5, 2022

  Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices to ensure the resident who had two unwitnessed falls on 7/17/2021 and 8/6/2021 (within 22 days) would not have a third fall with injury for one of two sampled residents (Resident 1). The facility failed to: 1. Provide supervision to Resident 1, who had poor trunk (main part of the body that contains the chest, abdomen, pelvis, and back) control with the inability to sit-up without falling over while up in the wheelchair and identified as a high risk for falls with a history of two unwitnessed falls. 2. Ensure Resident 1's wheelchair had both footrests in place to provide the resident with comfort and safety from falls. 3. […]

• No harm, potential for more than minimal, widespreadF726Feb 20, 2026

  Based on observation, interview, and record review, the facility failed to ensure the nursing staff had appropriate competencies and skill set to provide 94 out of 94 residents with care and services when:94 out of 94 licensed nursing staff were not in-serviced, and competency was not validated in the provision of Cardiopulmonary Resuscitation ([CPR] emergency lifesaving procedure when the heart stops beating) and emergency services for residents who are unresponsive.One of four nursing staff (Licensed Vocational Nurse (LVN) 4) did not have a performance evaluation (process organizations follow to assess an employee's work quality and skills over a specific period) in 2025.Three out of three Restorative Nursing Aides (RNA, trained nursing staff who help residents gain an improved quality… […]

• No harm, potential for more than minimal, widespreadF842Feb 20, 2026

  Based on observation, interview, and record review, the facility failed to ensure medical records for 5 of 14 sampled residents (Residents 3, 15, 37, 4, and 101) records were accurate, complete and readily accessible by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 1 did not document Resident 15's bismuth subsalicylate (a medication used to treat diarrhea, nausea, heartburn, indigestion and gas) oral suspension as administered on Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) when bismuth subsalicylate was not available in stock and was not administered on 2/18/2026.2. […]

• No harm, potential for more than minimal, widespreadF865Feb 20, 2026

  Based on interview and record review the facility's Quality Assessment and Assurance (QAA) Committee, affecting 94 out of 94 residents, failed to identify and implement corrective action to the systemic problems identified: Ninety-four (94) out of 94 licensed nursing staff were not in-serviced, and competency was not validated in the provision of Cardiopulmonary Resuscitation ([CPR] emergency lifesaving procedure when the heart stops beating) and emergency services for residents who are unresponsive.Three out of three Restorative Nursing Aides (RNA, trained nursing staff who help residents gain an improved quality of life by increasing their level of strength and mobility) were not in-service and competency was not validated at least annually on skill set needed to function as RNAs.Five… […]