Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Stonegates during CMS and state inspections, most recent first.
Two residents with Parkinson’s disease were ordered carbidopa-levodopa (Sinemet), but their MDS assessments inaccurately documented use of an anticonvulsant, despite no anticonvulsant orders in their records. Review of clinical records showed that carbidopa-levodopa was incorrectly coded as an anticonvulsant on multiple MDS assessments, and an RNAC reported having coded Sinemet this way for years based on prior instruction.
A resident’s care planning conferences were conducted without participation or documented input from the resident’s medical provider, despite multiple documented care conference dates. Sign-in sheets and a plan of care note showed attendance by an RN, LPN, RDN, and RNAC, while interviews with an LPN and the DON confirmed that medical providers do not attend or provide input for care plan/IDT meetings. This resulted in the comprehensive care plan not being developed and reviewed by the full required team of health professionals.
A resident with Parkinson’s disease, dementia, moderate cognitive impairment (BIMS 11), and a need for substantial/max assistance with bed mobility was observed on multiple occasions with bilateral quarter bed rails in the up position. Staff interviews indicated the resident required a hoyer lift for transfers, did not independently use the bed rails, and needed staff to guide her hands to hold the rails. Review of the clinical record showed no evidence that alternatives to bed rails were attempted, no bed rail assessment, no documented review of risks and benefits, no informed consent, and no bed rail care plan prior to installation and use of the bed rails.
A resident with Parkinson’s disease and anxiety disorder had multiple PRN lorazepam orders entered and renewed by a physician, who documented that the resident was experiencing positive benefit from the PRN Ativan and that it would be continued. However, review of the MARs and narcotic sheets for two consecutive months showed no recorded administrations of lorazepam, and the ADON confirmed that no doses had been given. This discrepancy showed that the medical record did not accurately or completely reflect the resident’s actual medication use.
A resident was observed in bed with bilateral quarter bed rails in the up position, and surveyors later determined that these bed rails had not been included in the facility’s routine, preventative maintenance program. During an interview with the NHA and DON, the facility could not provide evidence that the bed rails for this resident had undergone required preventative maintenance inspections, resulting in a deficiency related to bed safety equipment oversight.
The facility failed to provide mandatory Quality Assurance and Performance Improvement (QAPI) training to all staff, as shown by the absence of QAPI training documentation for a housekeeping employee and a dietary employee hired earlier in the year. During a staff training record review, surveyors found no evidence that these two employees had completed QAPI training, and the Scheduling Coordinator confirmed that such documentation was not available. The deficiency was discussed with the NHA, DON, and ADON during the survey exit conference.
The facility failed to ensure proper food storage and handling, risking foodborne illness. Observations revealed opened food items without proper dating, improper organization of raw animal foods, and an ice machine scoop left outside its container. Additionally, juice containers were undated, and items were stored on the floor. These issues were confirmed by staff and reviewed with facility leadership.
The facility failed to maintain proper infection control in the laundry room by leaving the door between the washer and dryer rooms open and storing clean linen and emergency water supplies in the soiled room. Staff confirmed these practices, which could lead to cross-contamination.
During a dining observation, it was found that staff used gloves while serving and feeding residents, violating their dignity. Four residents, all dependent for eating and severely cognitively impaired, were involved. Staff confirmed that glove use had been a practice since the COVID pandemic. The findings were reviewed with facility leadership.
A facility failed to collaborate with a hospice provider in developing a comprehensive care plan for a resident with cerebrovascular disease. The facility's care plan did not include hospice interventions, lacked pain monitoring orders, and showed poor communication with hospice staff. Critical lab results were not shared with hospice, and there was no documentation of hospice staff education to facility staff. Missing hospice documentation and irregular communication were noted during observations and staff interviews.
The facility failed to provide required dementia training for two staff members, E13 and E14, who were hired in 2015 and 2018, respectively. This deficiency was confirmed by the HR Director and discussed during the exit conference with the NHA, DON, and ADON.
Inaccurate MDS Coding of Carbidopa-Levodopa as an Anticonvulsant
Penalty
Summary
The deficiency involves inaccurate assessment and documentation of medications on the MDS for two residents with Parkinson’s disease. One resident was admitted with Parkinson’s disease and had an MD order for carbidopa-levodopa to be given three times daily. Despite this, the resident’s annual and significant change MDS assessments documented that the resident was taking an anticonvulsant, while review of the medication orders showed no anticonvulsant medications were ordered at those times. The facility inaccurately coded carbidopa-levodopa as an anticonvulsant on both MDS assessments. A second resident, also admitted with Parkinson’s disease and ordered carbidopa-levodopa four times daily, had a quarterly MDS assessment that documented use of an anticonvulsant, even though review of the medication orders showed no anticonvulsant medications were ordered. During an interview, the RNAC stated that they had been coding Sinemet (carbidopa-levodopa) as an anticonvulsant for years, since CMS started tracking anticonvulsant medications, and that this was how they had been taught to code it. This practice resulted in inaccurate MDS documentation for the resident’s medication regimen.
Failure to Involve Medical Provider in Interdisciplinary Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to include the required members, specifically the resident’s medical provider, in the care planning process for one resident reviewed for unnecessary medications. Review of the resident’s record showed a care conference sign-in sheet with review dates of 5/27/25, 8/21/25, and 11/13/25, listing participants as an RN, LPN, RDN, and RNAC, but no medical provider. In an interview, an LPN confirmed that residents’ medical providers do not attend or participate in care plan meetings. In a separate interview, the DON stated that the DON, RNAC, dietary, and family attend the care plan/IDT meetings and confirmed that residents’ medical providers do not participate, either by attending or providing input. The DON also reviewed a 11/13/25 progress note titled “Plan of Care Note” and confirmed there was no documentation of participation or input from the resident’s medical provider. These findings were reviewed with the NHA, DON, and ADON during the exit conference. The deficiency is specifically related to the requirement that the comprehensive care plan be developed, reviewed, and revised by a team of health professionals, which includes the resident’s medical provider. The documentation and staff interviews demonstrated that, for this resident, the care planning conferences were conducted without involvement or documented input from the medical provider, despite multiple care conference dates and a formal plan of care note in the record.
Failure to Assess, Document Alternatives, and Obtain Consent Before Bed Rail Use
Penalty
Summary
The deficiency involves the facility’s failure to complete and document required assessments and consents before installing and using bilateral quarter bed rails for one resident reviewed for accidents. The resident had an annual MDS showing a BIMS score of 11, indicating moderate cognitive impairment, and active diagnoses of Parkinson’s disease and dementia. The MDS also documented that the resident required substantial to maximum staff assistance for rolling in bed and moving from lying to sitting at the side of the bed. On two separate observations, the resident was seen in bed with bilateral quarter side rails in the up position during a nap and later the same day. Record review showed no evidence that alternatives to bed rails were attempted, no bed rail safety assessment, no documentation that risks and benefits were reviewed with the resident or representative, no informed consent, and no bed rail care plan for the use of bilateral bed rails. During interviews, a CNA stated the resident required assistance to turn in bed and used a hoyer lift for transfers, and that the resident did not use the bed rails. An LPN stated the resident had Parkinson’s disease with hand tremors and needed staff to guide her hands to the bed rails and direct her to hold on, after which the resident would hold on. In a combined interview with the NHA and DON, no bed rail information dated prior to the surveyor’s inquiry was provided, confirming the lack of required documentation prior to installation and use of the bilateral bed rails.
Inaccurate Documentation of PRN Lorazepam Use
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records for a resident with diagnoses including Parkinson’s disease and anxiety disorder. The resident was admitted on 11/3/23, and on 11/18/25 a physician ordered lorazepam 0.5 mg PO every 6 hours PRN for anxiety, nausea/vomiting, or agitation; this order was discontinued on 11/24/25. On 11/24/25, the same lorazepam PRN order was re-entered for 14 days and then discontinued on 12/8/25. On 12/8/25 at 3:52 PM, the physician documented in a progress note that the resident was on PRN Ativan, that positive benefit had been seen, and that the medication would be continued for one month. A new lorazepam PRN order for 30 days was entered on 12/8/25. Review of the resident’s November and December 2025 MARs and the facility’s narcotic sheet for lorazepam showed that no doses of PRN lorazepam were administered during those months. During an interview on 12/11/25, the ADON confirmed that no lorazepam doses had been given in November or December and stated that the resident was not taking the medication. Despite this, the 12/8/25 physician note documented that the resident had experienced positive benefit from PRN Ativan, with no medication administration records to corroborate that any doses had been given. This discrepancy demonstrated that the resident’s clinical record did not accurately and completely reflect the care and treatment provided.
Failure to Include Bed Rails in Routine Preventative Maintenance Program
Penalty
Summary
The deficiency involves the facility’s failure to include a resident’s bed rails in a routine, preventative maintenance program as required by the facility’s bed safety procedures. On 12/10/25 at 1:48 PM and again at 3:38 PM, surveyors observed Resident 18 in bed with bilateral quarter bed rails in the up position. During a combined interview on 12/11/25 at 11:35 AM with the NHA (E1) and DON (E2), surveyors reviewed the requirement that bed rails be inspected as part of the facility’s maintenance program. At that time, the facility was unable to provide evidence that this resident’s bed rails had been included in any routine, preventative maintenance inspections prior to 12/10/25. On 12/12/25 at 12:30 PM, this finding regarding the lack of documented preventative maintenance for the resident’s bed rails was reviewed with facility leadership, including the NHA, DON, and ADON, during the exit conference.
Failure to Provide QAPI Training to All Staff
Penalty
Summary
The facility failed to ensure all staff received mandatory training on the facility’s Quality Assurance and Performance Improvement (QAPI) program, as evidenced by missing training documentation for two of ten employees reviewed. Employee E8, a housekeeping staff member who began working on 3/26/25, and Employee E7, a dietary staff member who began working on 8/7/25, had no evidence in their records of having completed QAPI training. During record review on 12/11/25 at 1:24 PM, surveyors identified the absence of QAPI training documentation for these two employees, and at the same time, the Scheduling Coordinator (E12) confirmed that there was no evidence that E7 and E8 had completed QAPI training. The finding was later reviewed with the NHA (E1), DON (E2), and ADON (E3) during the exit conference on 12/12/25 at 12:30 PM. No residents were mentioned in the report, and no additional clinical or medical details were provided related to the deficiency.
Improper Food Storage and Handling in Facility
Penalty
Summary
The facility failed to ensure proper food storage, preparation, and service, which could lead to foodborne illness among residents. During an observation in the kitchen, it was noted that the walk-in refrigerator contained opened food items such as tartar, mandarins, and cherries, which were labeled with dates but lacked information on when they should be consumed, sold, or discarded. Additionally, bread slices and sesame buns were not dated. In the dry storage area, a bag of tortilla chips, a bag of grits, and a pan of almonds were also found without dates indicating when they were opened or prepared. These findings were confirmed by a Food Service Assistant. Further observations revealed that raw animal foods were not properly organized in the walk-in refrigerator, with raw fish stored next to red beans and above tomato paste, and raw pork stored above precooked rice and mushrooms, increasing the risk of cross-contamination. The ice machine scoop was found lying on the counter outside its protective container, and a case of water and a large container of ice cream were stored on the floor of the walk-in refrigerator and freezer. Additionally, juice containers in a refrigerator next to the ice machine were not dated when opened, a fact confirmed by a Dietary Aide who subsequently removed them. These issues were reviewed during an exit conference with the Nursing Home Administrator, Director of Nursing, and Assistant Director of Nursing.
Infection Control Deficiency in Laundry Room
Penalty
Summary
The facility failed to handle, store, and process linens properly in the laundry room, leading to potential infection control issues. During observations, it was noted that the door between the washer room and the dryer (clean) room was open, which should remain closed to prevent cross-contamination. Additionally, the soiled room contained inappropriate items such as an office desk, a resident emergency water supply, and a cart with clean linen, which should not be stored in the soiled area. Interviews with staff confirmed these observations and acknowledged that the doors should remain closed and that clean items should not be stored in the soiled linen room.
Violation of Resident Dignity During Dining
Penalty
Summary
During a dining observation, it was found that food service employees and nursing staff were using gloves while serving and feeding residents, which violated the residents' dignity in their home environment. Four residents, identified as R13, R15, R17, and R19, were observed during this incident. All four residents were documented as dependent for eating and severely cognitively impaired, according to their respective MDS assessments. The use of gloves in the dining room was confirmed by staff members, who reported that this practice had been in place since the COVID pandemic. The findings were reviewed with the Nursing Home Administrator, Director of Nursing, and Assistant Director of Nursing during the exit conference.
Failure to Collaborate with Hospice Provider in Care Plan Development
Penalty
Summary
The facility failed to collaborate with the hospice provider in developing a comprehensive written plan of care for a resident admitted to hospice with a diagnosis of cerebrovascular disease. The facility's hospice care plan, initiated prior to the resident's admission to hospice, did not incorporate the hospice provider's care plan interventions. This included the absence of orders to monitor pain at scheduled intervals and a lack of communication with the hospice provider regarding critical lab results indicating potential heart failure. Additionally, there was only one documented instance of facility staff contacting hospice about the resident's change in condition. The facility also lacked evidence of communication between the hospice nurse and facility staff, as there were no records of the hospice nurse providing education to the staff as outlined in the hospice care plan. Observations revealed the absence of a sign-in sheet for hospice staff and missing comprehensive assessment and plan of care update reports in the resident's hospice binder. Interviews with facility staff indicated irregular communication and coordination with hospice staff, with no documentation of discussions about the resident's status. The hospice provider later furnished the missing reports upon request by the surveyor.
Lack of Dementia Training for Staff
Penalty
Summary
The facility failed to ensure that two out of five sampled employees received the required training on dementia management. Specifically, staff members E13 and E14 did not have evidence of completing dementia training. E13 was hired on August 19, 2015, and E14 was hired on March 28, 2018. This deficiency was confirmed during an interview with E15, the HR Director, who acknowledged the lack of dementia training for these employees. The findings were reviewed during the exit conference with the Nursing Home Administrator (E1), Director of Nursing (E2), and Assistant Director of Nursing (E3).
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Greenville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willowbrooke Court At Country House | 0.9 mi | ★★★★★ | 0 | 0 |
| Excelcare At Wilmington Llc | 2.3 mi | ★★★★★ | 2 | 0 |
| Kentmere Rehabilitation And Healthcare Center | 2.6 mi | ★★★★★ | 5 | 0 |
| Regal Heights Healthcare & Rehab Center | 3 mi | ★★★★★ | 3 | 0 |
| Regency Healthcare & Rehab Center | 3.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.