The Nursing and Rehab Center at Stadium Place

In the surveyor’s words

From the most serious findings on record at The Nursing and Rehab Center at Stadium Place, in the surveyor’s own words.

• Actual harm, isolatedF690Jan 23, 2023

  Based on medical record review, observations, and interview with facility staff, it was determined that the facility failed to address and implement interventions for a resident admitted with a suprapubic catheter. This was identified during the review of 1 of 1 residents with suprapubic catheters. The findings include: On 1/4/23 Surveyor met with Resident #20 during the initial tour. During this initial meeting and interview, Resident #20 reported that s/he was in discomfort and believed that they had a urinary tract infection (UTI) as there was some pressure and discomfort in their abdomen and they could tell that the catheter was probably clogged as s/he could feel it was leaking. Surveyor asked if this was reported to the staff, and s/he stated that staff were aware. […]

• No harm, potential for more than minimal, widespreadF727Jul 14, 2026

  Based on record review and staff interview, it was determined that the facility failed to ensure there was a Registered Nurse working at least 8 hours a day. This was evident in 3 out of 14 days reviewed during the Staffing task in the recertification survey. The findings include:On 7/10/2026 at 9:16 AM, a review of the staff assignment sheets for 6/25/2026 to 7/9/2026 were reviewed. The facility did not have a Registered Nurse (RN) working for any shift on 6/30/2026, 7/4/2026, and 7/5/2026. On 7/10/2026 at 9:44 AM, an interview with the Director of Nursing was conducted. When asked if they were aware that the facility did not have Registered Nurses on 6/30/2026, 7/4/2026, and 7/5/2026, they stated that they were aware. […]

• No harm, potential for more than minimal, widespreadF921Jul 14, 2026

  Based on resident interview, observations, and staff interview, it was determined that the facility failed to maintain a functional and comfortable environment. This was evident on 4 out of 4 units reviewed for environment.The findings include:1.On 7/7/2026 at 12:22 PM, The 1st floor shared bathroom's walls were bubbled with unpainted repairs on the opposing walls. When asked what was being done to repair the walls, Staff #1 stated that repairs have been completed for the 2nd and 3rd floor. Staff #1 stated that he will be repairing the 1st floor shared bathroom next. Staff #1 stated that he made administration aware that paper towels were causing the pipes to clog resulting in leaks and damaging the walls of the lower bathrooms. […]

• No harm, potential for more than minimal, widespreadF725Oct 17, 2025

  Based on observations, record reviews, and interviews, it was determined that the facility failed to ensure adequate nursing staff coverage as required and failed to ensure that call bells were answered in a timely manner. This deficient practice was evident for all four nursing units during the complaint survey.The findings include:On 10/16/25 at 8:07AM, during the initial observation of the second-floor unit (unit two of four total floors and units), the surveyor asked Geriatric Nursing Assistant (GNA) #1 a question. The GNA responded to the question and then continued assisting residents on unit 2. The surveyor then proceeded to the third-floor unit. At 8:33AM, during the observation of the third floor, the surveyor observed GNA #1 assisting residents. […]

• No harm, potential for more than minimal, patternF550Jul 14, 2026

  Based on interviews, record reviews, and observations, it was determined that the facility failed to promote and maintain resident dignity by failing to answer residents' call lights promptly to address residents basic care needs. This was evident for 4 (Resident #17, #2, #60 and #22) out of 8 residents reviewed for dignity during the recertification survey.The findings include:On 07/06/2026 at 9:34 AM, an interview with Resident #17 was conducted. They reported that it took too long for call bells to be answered, so they avoided going to the bathroom a lot therefore avoiding the need to call a staff member to change their brief. When asked for a specific date or time, they responded that it happened frequently and on various shifts. […]