Stonegates

Inspectors wroteBased on record review and interview, it was determined that for two (R18 and R27) out of three residents reviewed for accidents, the facility failed to accurately reflect R18 and R27's status by documenting their medication, carbidopa-levodopa, as an anticonvulsant.

Inspectors wroteBased on interview and record review, it was determined that for one (R29) out of five residents reviewed for unnecessary medications, the facility failed to include the required members in the care planning conference.

Inspectors wroteBased on observation, interview and record review, it was determined that for one (R18) out of three residents reviewed for accidents, the facility failed to have evidence of attempted alternatives, bed rail assessment, review of the risks and benefits and obtain informed consent prior to installation and use of bilateral bed rails.

Inspectors wroteBased on record review and interview, it was determined that for one (R18) out of three residents reviewed for accidents, the facility failed to ensure each residents' records were accurate and complete.

Inspectors wroteBased on observation and interview, it was determined that for one (R18) out of three residents reviewed for accidents, the facility failed to ensure that R18's bed rail was included in a routine, preventative maintenance program.

Inspectors wroteBased on record review and interview, it was determined that for two (E7 and E8) out of ten employees reviewed for training, the facility lacked evidence of QAPI training.

Inspectors wroteBased on observation and interview it was determined that the facility failed to ensure food was stored, prepared and served in a manner that prevents food borne illness to the residents.

Inspectors wroteBased on observation and interview it was determined that for two random observations of the laundry room, the facility failed to handle, store and process linens to prevent the spread of infection. 12/4/24 9:30 AM - The following was observed in the laundry area: - The door from the washer room to the dryer (clean) room was open. -The room with the washing machines had blue rags on the floor to the right of the washer and a cell phone was plugged in and laying on top of a washer. -The soiled room contained an office desk, resident emergency water supply, a cell phone on the desk and a cart with clean linen that had a cover on it. 12/4/24 9:35 AM - In an interview E16 (Laundress) confirmed the door was open. [...]

Inspectors wroteBased on a random observation and interview it was determined that four (R13, R15, R17 and R19) residents observed during dining, food service employees utilized gloves while in the dining room to serve residents and nursing staff utilized gloves in the dining room to feed residents violating resident's dignity in their home environment.

Inspectors wroteBased on interview, record review and review of other documentation, it was determined that for one (R17) out of one resident reviewed for hospice, the facility failed to collaborate with the hospice provider in the development of a written plan of care.

Inspectors wroteBased on interview and review of other facility documentation it was determined that the facility failed to ensure that two (E13 and E14) out of five sampled employees received training on dementia management.

Inspectors wroteRevised post IDR Based on interview and record review, it was determined that for two (R14 and R38) out of two residents reviewed for accidents, the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents. R14, a cognitively impaired resident with dementia and identified as high risk for wandering, eloped from the building on 2/18/23 and was found outside on the community grounds by a bystander. R14 was at risk of a severe adverse outcome. An IJ (immediate jeopardy) was identified on 12/4/23 at 2:17 PM and abated on 12/4/23 at 11:59 PM. For R38, a cognitively impaired resident who was at high risk for falls upon admission, the facility failed to implement appropriate person-centered fall interventions taking into consideration her continued impulsivity, lack of safety awareness and her diagnosis of a urinary tract infection (UTI). [...]

Inspectors wroteBased on record review and interview, it was determined that for four (E13, E21, E26 and E27) out of seven Certified Nursing Assistants (CNAs) reviewed for in-service education, the facility failed to ensure each CNA received at least twelve hours of in-service training per year.

Inspectors wroteBased on record review and interview, it was determined that for one (R38) out of three residents reviewed for hospitalization, the facility failed consult with the resident's physician and notify R38's resident representative of a fall on 10/5/22 which resulted in an injury and had the potential for requiring physician intervention.

Inspectors wroteBased on record review and interview, it was determined that for one (R38) out of three residents sampled for hospitalization, the facility failed to have an admission order for R38's immediate care of her fractured finger.

Inspectors wroteBased on interview and record review, it was determined that for one (R6) out of seventeen residents reviewed for assessments, the facility failed to ensure the accuracy of R6's Resident Assessment Instrument (RAI).

Inspectors wroteBased on record review and interview, it was determined that for one (R38) out of three residents reviewed for hospitalization, the facility failed to develop and implement a baseline care plan for R38's fractured finger.

Inspectors wroteBased on record reviews and interviews, it was determined that for one (R2) out of one resident sampled for pressure ulcers and one (R38) out of three residents sampled for hospitalizations, the facility failed to revise each residents' care plan.

Inspectors wroteBased on record review and interview, it was determined that for two (E27 and E28) out of five CNAs reviewed for performance reviews, the facility failed to ensure each CNA had an annual performance review.

Inspectors wroteBased on record review and interviews, it was determined that for one (R26) out of five residents reviewed for immunizations the facility failed to offer the recommended pneumococcal vaccine.