Life Care Center of Stonegate

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#2 and #4) three residents reviewed for accidents and hazards received adequate supervision to prevent accidents out of four sample residents. Resident #2, who had severe cognitive impairment, was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, a right ankle fracture and right shoulder ligament repair following a fall at home. The resident's right ankle was immobilized in an orthopedic boot and her right arm was immobilized in a sling. The facility identified upon admission that the resident was a high risk for falling and initiated a baseline fall care plan. However, the baseline fall care plan failed to include interventions to prevent falls for the resident. On 8/17/25 Resident #2 sustained a fall in her room and complained of right wrist pain. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to develop and implement a baseline care plan for within 48 hours of admission that included the minimum healthcare information necessary to properly care for the immediate needs for two (#2 and #4) of three residents reviewed out of four sample residents. Specifically, the facility failed to:-Implement a baseline care plan that included fall prevention interventions in order to prevent a fall with major injury on 8/17/25 for Resident #2; and,-Implement a baseline care plan that included information for fracture care in order to properly care for Resident #2's admitting diagnoses of a right ankle fracture and right shoulder ligament repair and Resident #4's admitting diagnoses of thoracic spine and rib fractures.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#287) of five residents out of 35 sample residents was free from significant medication errors. Resident #287 was admitted to the facility on [DATE] for skilled nursing care after a failed left total knee revision. Secondary diagnoses included hypertension (high blood pressure), post-procedural pain and a history of heart failure. Resident #287's physician's orders for medications, upon his admission to the facility from the hospital on 6/20/24, included an order for carvedilol (a medication used to treat high blood pressure and heart failure) 6.25 milligrams (mg) twice daily for heart rate and blood pressure (BP). The hospital's list of physician ordered medications was verified by the facility's physician. [...]

Inspectors wroteBased on record review and interviews, the facility failed to honor resident choices for four (#71, #130, #183, and #186) of eight residents reviewed for self-determination out of 35 sample residents. Specifically, the facility failed to provide bathing for Resident #71, #130, #183 and #186 per their preferences.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for three ( #181, #177 and #240) of nine residents reviewed out of 35 sample residents. Specifically, the facility failed to: -Ensure Resident #181 and Resident #177 received skin care as ordered by the physician; and, -Ensure Resident #240's provider was notified timely of a delay in starting antibiotics and ensure the resident's vital signs were monitored during a change in condition.

Inspectors wroteVII. Resident #183 A. Resident status Resident #183, age greater than 65, was admitted on [DATE]. According to the September 2024 CPO, diagnoses included paraplegia, high blood pressure, pressure ulcer, muscle weakness and a complication of an internal fixation device (surgical implant) of the vertebrae. The 10/2/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. He was totally dependent on assistance for toileting hygiene, lower body dressing and transfers. He needed substantial/maximum assistance for bed mobility (movement back and forth in bed, sitting to lying/lying to sitting) and set-up help only with eating. The MDS assessment documented the resident had a stage 3 pressure ulcer upon admission and was at risk for developing pressure injuries. The assessment documented the resident did not refuse care. B. [...]

Inspectors wroteIV. Additional EBP failures A. Observations On 9/30/24 at 2:13 p.m. an unidentified staff member knocked on the door to Resident #177's room. Resident #177 had an indwelling foley catheter. Prior to entering the resident's room, the staff member donned a surgical mask, opened the door, entered Resident #177's room and told the resident he was going to have wound care. A second unidentified staff member then entered room Resident #177's room. At 2:23 p.m. the two unidentified staff members exited Resident #177's room. One staff member exited with a clear trash bag of disposable items. At 2:25 p.m. another unidentified staff member knocked on Resident #177's door, entered the resident's room holding a stack of clean, folded bedding and told the resident they were there to change the resident's bedding. [...]

Inspectors wroteBased on record review and interviews, the facility failed to develop, implement and maintain an effective training program for all staff, including contract agency staff, based on the facility assessment and resident population. Specifically, the facility failed to complete orientation skills checklists and receipt of orientation packets, which included information for general orientation of the facility, medication administration, electronic medical record access, laundry procedures, resident transfers, gait belt usage and information on nursing documentation and admission of residents, for agency nursing staff.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#23) of two residents reviewed for dialysis care out of 35 sample residents received dialysis services consistent with professional standards of practice. Specifically, the facility failed to consistently complete the pre- and post-dialysis facility assessment section on dialysis communication forms for Resident #23.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure residents and or their representatives were provided prompt efforts by the facility to resolve grievances for three (#1, #2 and #6) of three residents reviewed out of five sample residents. Specifically, the facility failed to address, resolve, document and follow up on grievances for: -Resident #1 regarding cold shower temperatures; -Resident #2 regarding cold shower temperatures and call light response times; and, -Resident #6 regarding call light response times. -Additionally, unnamed residents in the resident council complained of call light response times with no follow up documented by the facility.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide activities that meet the interests and choices of residents for three (#32, #15 and #205) of four out of 28 sample residents. Specifically, the facility failed to to offer and provide personalized activity programs for Resident #32, #15 and #205.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible. Specifically, the facility failed to: -Maintain how water temperatures coming out of the tap and showers in resident care areas for resident bathing and grooming tasks at a safe water temperature to avoid scalding and residents from sustained burns to the body; and -Ensure the Resident #36 was being assisted with the current methods of transfer assistance as documented in the resident's care plan.

Inspectors wroteBased on record review and interviews, the facility failed to ensure facility nurses and certified nurse aides (CNA) were able to demonstrate competencies in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Specifically, the facility failed to ensure nursing staff had completed competencies prior to providing skilled services as ordered by the physician for three out of three nurses reviewed for competencies.

Inspectors wroteBased on observations and interviews the facility failed to ensure two out of three medication refrigerators stored and secured drugs and biologicals in accordance with accepted professional standards. Specifically, the facility failed to: -Ensure controlled medications were in a double locked storage area where the locked controlled substance medication containment unit was secured to the refrigerator; -Ensure each medication cart was locked when nurse was not at the cart; -Ensure alcohol for resident consumption was not stored in the same refrigerator as resident medications; and, -Ensure controlled medications for disposal were kept in a double locked area until disposal.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection for one out of two units at the facility. Specifically, the facility failed to: -Ensure housekeeping staff engaged in hand hygiene; -Ensure housekeeping staff cleaned resident rooms appropriately; -Ensure nursing staff disinfected shared equipment (vitals machines and lifts) between residents; -Ensure nursing staff had appropriate infection control practices during wound care; and, -Ensure nursing staff performed hand hygiene between residents.

Inspectors wroteBased on record review and interview, the facility failed to provide training to their staff that at a minimum educate staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth, procedures for reporting incidents of abuse, neglect, exploitation, or misappropriation of resident property and dementia management and resident abuse prevention. Specifically, the facility failed to: -Provide annual abuse identification and prevention training for one of five certified nurse aides (CNA) and one of two nurses reviewed; and, -Provide initial hire orientation and/or annual dementia management training for three out of five CNAs and one of two nurses reviewed.

Inspectors wroteBased on observations, record review and interviews, the facility failed to promote self-determination for two (#36 and #205) of six residents reviewed for preferences and choices of 28 sample residents. Specifically, the facility failed to honor the resident preferences for bathing and implement bathing care based on the resident self-determined preferences. Identified resident preferences included: -Being able to take a bath when requested (Resident #36 and #205); and, -Being asked about daily routine and being able to have a plan for staff to follow particularly for bathing needs (Resident #36 and #205).

Inspectors wroteBased on record review and interviews, the facility failed to ensure drug regimens were free from unnecessary medications for one (#36) of five residents out of 28 sample residents. Specifically, the facility failed to ensure Resident #36 drug regimen must be free from unnecessary drugs, in excessive doses where there was potential for adverse consequences which indicate s the dose should be reduced or discontinued; and for excessive duration without clinical justification.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the minimum data set assessment (MDS) accurately reflected residents' status for three (#4, #7 and #25) of 12 out of 24 sample residents. Specifically, the facility failed to appropriately assess, according to the Resident Assessment Instrument (RAI): -Cognitive patterns, mood and behavior for Resident #4; -Health conditions for Resident #7; and, -Functional status and health conditions for Resident #25.