Stonegate Nursing and Rehabilitation

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the interdisciplinary team determined if a resident was able to self-administer medications for 1 of 15 residents (Resident #20) reviewed for resident rights. The facility failed to ensure Resident #20, was clinically appropriate to self-administer nasal spray that were at the resident's bedside. The failure had the potential to place residents at risk for unsafe drug administration.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary and comfortable interior for 1 of 33 residents (Resident #64) reviewed for sanitary and comfortable environment. The facility failed to maintain Resident #64's wheelchair in a sanitary condition leaving food, liquid spills, dirt, and debris to collect down both sides of the wheelchair when observed on 02/10/26. This failure could place residents at risk of contamination and infections.

Inspectors wroteBased on interview and record review, the facility failed to assess each resident quarterly (every 3 months) using the MDS form specified by the state and approved by CMS for 1 of 5 residents (Resident #56) reviewed for assessments. The facility failed to ensure Residents #56's quarterly MDS assessment was completed within three months from the previous assessment. This failure could place residents at risk of not receiving necessary care or receiving inappropriate care for their conditions.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 1 of 5 residents (Resident #21) reviewed for nutritional status. The facility failed to recognize, evaluate, and address timely interventions and prevent weight loss when Resident #21 experienced severe weight loss of 6.48% (8 pounds) from 01/12/26 to 02/12/26. This failure could place residents at risk for improper care, weight loss, malnutrition, and overall health decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 2 medication carts (200 Hall) and 2 of 2 residents (Residents #1 and #2) reviewed for pharmacy services. The facility failed to ensure the 200 Hall nurses' medication cart had accurate narcotic counts for Residents #1 and #2. This failure could place residents at risk for medication errors, drug diversion, and delay in medication administration.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 1 residents (Resident #3) reviewed for accommodation of needs. The facility failed to ensure Resident #3 had access to his call light. This failure could place residents at risk of not being able to call for help when needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: The facility failed to ensure food temperatures were checked on 01/03/25 while on the steam table before serving residents between 7:00 AM to 8:30 AM. These failures could place residents, who receive food from the kitchen, at risk for food contamination and foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments for two (Medication Cart #1 and Medication Cart #2) of four medication carts and nurses' station counter (Hall 200- East Station) reviewed for medication storage. 1. The facility failed to lock Medication Cart #1 and Medication Cart #2 on 01/02/25, leaving all medications on the cart accessible on Hall 100 (West Station). 2. The facility failed to secure medications on the nurses' station counter on Hall 200 (East Station) on 01/03/25 at 5:30 AM. These failures could place residents at risk for drug diversions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 2 of 6 residents (Residents #34 and #3) reviewed for abuse. 1. The facility failed to ensure Resident #34 had the right to be free from abuse when she was verbally and mentally abused by the Weekend Activities Assistant on 07/14/24. 2. The facility failed to ensure Resident #3 had the right to be free from abuse when he was verbally and mentally abused by CNA U on 07/08/24. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 07/08/24 and ended on 07/14/24. The facility had corrected the noncompliance before the investigation began. These failures placed residents at risk of abuse, trauma, and psychosocial harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse and neglect of residents for 2 of 6 residents (Residents #34 and #3) reviewed for abuse. 1. The facility failed to protect Resident #34 from retaliation after the Weekend Activities Assistant was suspended based on an allegation of abuse on 07/14/24. 2. The facility failed to protect Resident #3 from verbal and mental abuse by CNA U on 07/08/24. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 07/08/24 and ended on 07/14/24. The facility had corrected the noncompliance before the investigation began. These failures placed residents at risk of ongoing abuse, trauma, and psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure all alleged violations involving abuse or neglect were reported to the facility Administrator immediately but no later than 2 hours for 1 of 6 residents (Resident #34) reviewed for abuse and neglect. The facility failed to immediately notify their Abuse Coordinator (the Former Administrator) when the Weekend Activities Assistant had yelled at Resident #34 at the nurse's station in front of other residents and staff on 07/14/24. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 07/14/24 and ended on 07/14/24. The facility had corrected the noncompliance before the investigation began. This failure placed residents at risk of continued abuse, trauma, and psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident was provided with a nourishing, palatable, well-balanced diet that met his or her daily nutritional and special dietary needs, taking into consideration the preferences of 2 of 23 residents (Residents #41 and #239) observed. The facility failed to have an adequate supply of milk for all residents. This failure had the potential to affect all facility residents who consumed food from the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain good grooming, and personal hygiene for 1 of 22 residents (Resident #74) reviewed for ADL care. The facility failed to ensure Resident #74's fingernails were cleaned and cut. This failure could place residents at risk for poor hygiene, dignity issues, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 of 3 residents (Resident #8) reviewed for respiratory therapy. LVN Y failed to ensure Resident #8's nasal cannula was changed and dated according to doctor's orders on 10/20/24. This failure could lead to respiratory infections, poor air quality, and not having their respiratory requirements met.

Inspectors wroteBased on observation and interview, the facility failed to ensure, in accordance with State and Federal laws, the facility stored all drugs and biologicals in locked compartments for 1 of 5 carts (100 Hall Nurse cart) reviewed for storage. LVN C failed to secure the nurse medication cart for 100 Hall. This failure could place residents at risk of obtaining medications not prescribed to them.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the menu was followed for the lunch meal for 1 of 5 residents (Resident #9) reviewed for food and nutrition services. The facility failed to ensure residents on a pureed diet were served pureed bread and pureed angel food cake during the lunch meal on 10/23/24. This failure could place residents at risk for unwanted weight loss, hunger, and metabolic imbalances.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide food prepared in a form designed to meet individual needs for 1 of 5 residents (Resident #9) reviewed for food consistency. The facility failed to ensure Resident #9's pureed carrots were free of whole slices of carrots. This failure placed all residents, especially those with swallowing issues, at risk of aspirating or choking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were maintained on each resident that were accurately documented for 1 of 3 residents (Resident #8) reviewed for accuracy of clinical records. The facility failed to ensure LVN Y accurately documented on Resident #8's TAR that her nasal cannula was not changed on 10/20/24 as ordered. This failure could place residents at risk of inaccurate medical records that could affect monitoring and medical services provided.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored securely for 2 (Resident #30 and Resident #73) of 18 residents observed for medication storage. 1. Resident #30 had 1 bottle of Tums pills stored at the resident's bedside table not locked in a lock box or secured in the medication cart or medication room. 2. Resident #73 had unidentified cream at her bedside table and unidentified pills in a plastic cup on her bed not locked in a lock box or secured in the mediation cart or mediation room. This failure could place residents at risk of overmedication or adverse drug reactions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 2 (Resident #65 and Resident #37) of 6 residents reviewed for enteral nutrition, in that: 1. The facility failed to appropriately label formula bag for Resident #65. 2. The facility failed to follow Resident #37's physician orders for enteral feeding. These failures could affect residents receiving enteral nutrition/hydration and place them at risk of health complications and decline in health.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who need respiratory care were provided such care, consistent with professional standards of practice for 1 (Resident #37) of 7 resident reviewed for respiratory care. The facility failed to follow the physician orders for Resident #37's oxygen. This failure placed residents who received oxygen therapy at risk of respiratory complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the clinical record were maintained in accordance with accepted professional standards and practices and were complete and accurately documented for 1 (Resident #37) of 18 residents records reviewed for treatment documentation. 1. LVN B documented Resident #37 had been connected to her g-tube feedings at 1PM but resident was not connected to her g-tube feedings until 3PM. 2. LVN C documented Resident #37 had been receiving oxygen therapy, but observation revealed resident was not receiving oxygen therapy. These failures could affect the residents medical record not being an accurate representation of the resident's medical condition or medical needs.