Stonegate Nursing And Rehabilitation

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the interdisciplinary team determined whether Resident #20 was clinically appropriate to self-administer medication. Resident #20’s admission MDS reflected moderate cognitive impairment with a BIMS score of 12, and her diagnoses included hypertension, renal insufficiency, and an anxiety disorder. Her care plan did not address medication use at the bedside, and the clinical record contained no assessment showing whether she was able to self-administer medications. Her order summary and MAR also showed no physician order for nasal spray. During observation, Resident #20 had a bottle of nasal spray at her bedside and stated she had been using it herself for a while without staff assistance. She said she kept it nearby because her nose sometimes got dry and she used it as needed to breathe comfortably, and she reported staff had never questioned the medication being at her bedside. Staff interviews confirmed there was no resident self-administration process in place, and the LVN removed the nasal spray from the room after observing it. The DON and ADON stated residents were not allowed to self-administer medications and that medications found in resident rooms were to be removed and reported, while the facility’s medication storage policy stated that all drugs and biologicals were to be stored in a safe, secure, and orderly manner.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary and comfortable interior for Resident #64 by not keeping his manual wheelchair clean. Resident #64 was an [AGE]-year-old male with diagnoses including muscle weakness and diabetes, and his Quarterly MDS reflected a BIMS score of 09 indicating moderately impaired cognition. His care plan noted an ADL self-care performance deficit related to cognitive deficit secondary to dementia disease progression, impaired decision making, and limited mobility, and he required assistance with transfers and bed mobility. On observation, Resident #64 was seen in his wheelchair with food particles, liquid spills, dirt, and debris on both sides of the chair. This condition was observed on 02/10/26 and again on 02/11/26. Resident #64 stated he used the wheelchair throughout the facility and did not recall it being cleaned. CNA A and LVN B both stated overnight shift aides were responsible for cleaning resident wheelchairs, and LVN B said she would have reported the dirty wheelchair to the ADON if she had seen it. The DON stated the overnight shift had a wheelchair cleaning schedule, but there was no evidence the wheelchair had been cleaned and aides did not document when the task was completed. The Administrator stated CNAs on the overnight shift were responsible for ensuring wheelchairs were cleaned according to the schedule.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to complete Resident #56’s quarterly MDS assessment within the required 3-month timeframe. Record review showed the resident had an entry MDS completed on 10/02/25 and a significant change MDS completed on 10/09/25, but the quarterly MDS dated 01/09/26 was still in progress and had not been completed. The resident’s original admission date was 05/07/24 and her most recent readmission date was 10/02/25. During interview, the Regional MDS Coordinator stated she knew the quarterly MDS for Resident #56 was still in progress and said the assessment was overdue beyond the usual 92-day quarterly timeframe. She explained the facility had recent personnel changes and had gone a few months without a full-time MDS Coordinator, and said no one was monitoring to ensure assessments were completed timely. The DON stated she knew the Regional MDS Coordinator had been working to get caught up on MDS assessments and said she had nothing to do with monitoring or completing them, while also stating she expected all resident MDS assessments to be completed timely. The facility policy titled Resident Assessment Instrument stated the Assessment Coordinator is responsible for ensuring the Interdisciplinary Assessment Team conducts timely resident assessments at least quarterly.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain acceptable nutritional status for one resident who experienced severe unplanned weight loss. Resident #21 was a male with diabetes, seizure disorder/epilepsy, and Down syndrome, and his MDS reflected short-term and long-term memory problems and severe impairment in daily decision making. His significant change in status assessment and care plan identified him as at risk for weight fluctuations, with documented recent weight loss and a plan for weekly weights and RD evaluation. Record review showed Resident #21 weighed 120 pounds in November, 108 pounds on readmission in January, and 100.6 pounds in February, reflecting a 6.48% loss from 108 pounds to 100.6 pounds in one month. The nutrition assessment dated 01/20/26 noted no new weight in the EHR, used the recent 108-pound weight to estimate needs, and recommended a protein supplement, vitamin C, zinc, and weekly weights x4. The facility’s monthly weights list and CNA weight notes showed additional weights of 105.7, 103.2, 99.4, and 100.1 pounds, but these weights were not entered into the EHR for trending. The facility’s protocol defined 1-month weight loss greater than 5% as severe. Interviews showed staff knew Resident #21 had weight loss and needed assistance to eat, but the weight information was not effectively tracked or communicated. The CNA stated she obtained and wrote down weights and gave copies to ADON F, but she did not trend them. ADON H stated ADON F was responsible for tracking and trending weights, while ADON F said she only entered weights into the EHR and was unsure why the weights were not entered. The RD stated she emailed her recommendations to the DON after identifying the weight loss and was concerned that the facility did not document weekly weights or provide the recommended protein supplement. The DON stated the RD’s recommendations were seen during an audit, that the email may have been lost in the shuffle, and that the doctor was not made aware of the severe weight loss until later. The physician stated she would have added nutritional interventions earlier if she had known about the weight loss.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate pharmaceutical services, specifically in the accurate acquiring, receiving, dispensing, and administering of narcotic medications for residents. This deficiency was observed in the 200 Hall nurses' medication cart, where discrepancies in narcotic counts were noted for two residents. For one resident, the narcotic administration record indicated 54 pills remaining, while the blister pack count was 53 pills. For another resident, the record showed 49 pills remaining, but the blister pack count was 48 pills. These discrepancies were due to the failure of RN A to sign off on the narcotic administration record after administering the medications. Interviews with RN A, the ADON, and the DON revealed that RN A admitted to administering the medications but forgetting to document the administration on the narcotic log and the medication administration record (MAR). Both the ADON and the DON expressed that their expectation was for staff to document narcotic administration accurately to prevent incorrect counting and potential medication errors. The facility's controlled substances policy requires compliance with laws and regulations related to handling and documentation of controlled substances, which was not adhered to in this instance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident had access to his call light, which is a necessary accommodation for residents to call for help when needed. The resident, a male with severe cognitive impairment and a BIMS score of 3, required substantial assistance with all activities of daily living. Observations revealed that the call light was clipped to the ceiling-suspended curtain, out of the resident's reach. Despite the resident's understanding of how to use the call light, he did not realize it was not within reach and had not called for help. The CNA assigned to the resident stated that she had left the call light within reach after dressing him, but could not explain how it ended up clipped to the curtain. The CNA acknowledged the importance of ensuring the call light was accessible during her rounds. The Director of Nursing (DON) confirmed that the expectation was for call lights to be within reach at all times and that staff should check this during rounds. The facility's policy on call lights, dated October 2010, also required that call lights be within easy reach when residents are in bed or confined to a chair.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to professional standards for food service safety by not checking food temperatures on the steam table before serving breakfast to residents. On the morning of January 3rd, various food items such as oatmeal, scrambled eggs, pureed, and mechanical soft meat were observed on the steam table uncovered. Additional items like omelets, toast, and bacon were added to the steam table without temperature checks. The dietary staff member responsible for plating the food admitted to not checking the temperatures due to being behind schedule, which could result in residents receiving food that is either too cold or too hot. The Dietary Manager confirmed that the staff member was supposed to check the temperatures before serving and acknowledged that the temperature logs for December and January were incomplete. The manager stated that the temperatures were recorded elsewhere and later updated in the log book, which is against the facility's policy that requires temperatures to be logged as they are checked. The facility's Food Preparation and Service policy outlines the importance of maintaining food temperatures outside the danger zone of 41 to 135 degrees Fahrenheit to prevent foodborne illnesses, but this protocol was not followed during the observed breakfast service.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as required by professional principles. On two separate occasions, Medication Cart #1 and Medication Cart #2 were left unlocked, with drawers open and accessible to residents in Hall 100 (West Station). Additionally, medications were left unattended on the nurses' station counter in Hall 200 (East Station), making them easily accessible to residents. These observations were made during a survey conducted on January 2nd and 3rd, 2025. Interviews with multiple staff members, including medication aides and licensed vocational nurses, confirmed that medication carts and medications should be secured at all times when not in use. The Director of Nursing and Assistant Directors of Nursing reiterated that medications should be put away immediately upon delivery and that medication carts must be locked when not in use. A review of the facility's policy on the security of medication carts, revised in April 2007, also indicated that carts must be locked to prevent unauthorized access. Despite these policies, the facility's failure to secure medications could potentially lead to drug diversions.

Penalty

Inspection fine: $16,801

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect two residents from verbal and mental abuse by staff members. Resident #34, a female with no cognitive impairment but diagnosed with anxiety, depression, and a psychotic disorder, was verbally and mentally abused by the Weekend Activities Assistant. The incident occurred when the assistant publicly confronted Resident #34 about a personal matter, causing her embarrassment and distress. Witnesses reported that the assistant yelled at Resident #34 in front of others, which led to the resident feeling humiliated and isolated. The assistant's behavior was perceived as retaliatory, as she later confronted Resident #34 in her room, blaming her for the assistant's termination. Resident #3, a male with cerebral palsy and no cognitive impairment, experienced verbal abuse from a CNA. The resident recalled the CNA being mean and yelling at him, which he felt was abusive. This incident left Resident #3 feeling bad about the situation. The report indicates that the CNA was subsequently fired, and Resident #3 noted that staff now treat him well. These incidents highlight the facility's failure to ensure a safe and respectful environment for its residents, as both residents experienced distress and emotional harm due to the actions of staff members. The facility's investigation confirmed the abuse, and the staff involved were terminated for their misconduct.

Removal Plan

• Activity director was sent home on suspension as a precaution.
• Education continues for MANE.
• Additional training added regarding separation of employees and residents and a healthy, professional boundary.
• Psych services were called.
• MD called.
• Medical director informed.
• Planned call with Resident #34's family member to review findings of the investigation.
• Recommend termination of employee for violating policy for abuse, neglect, and retaliation/fear of reprisal for any resident.
• Continue training and add communications and inappropriate texts and messaging to the training.
• Separation is required for employees.
• Ongoing monitoring for resident to ensure there are no lasting adverse outcomes related to this incident.
• Counseling as necessary for support services for resident.
• SW and Administrator will continue checking ins.

Penalty

Inspection fine: $16,801

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse and neglect of residents, specifically affecting two residents. Resident #34 was not protected from retaliation after an incident involving the Weekend Activities Assistant, who was suspended following an allegation of abuse. The incident involved the Weekend Activities Assistant publicly confronting Resident #34 about a personal matter, which led to the resident feeling embarrassed and isolated. Witnesses reported that the Weekend Activities Assistant yelled at Resident #34 in front of others, which was perceived as abusive behavior. The situation was exacerbated when the Weekend Activities Assistant allegedly confronted Resident #34 in her room, blaming her for the suspension. Resident #34, a female with no cognitive impairment but diagnosed with anxiety disorder, depression, and psychotic disorder, was emotionally affected by the incident. The resident reported feeling tearful and withdrawn following the confrontation. The facility's staff, including the Housekeeping Supervisor and the Social Worker, confirmed that the Weekend Activities Assistant's actions were inappropriate and contributed to Resident #34's distress. The Social Worker noted that the Weekend Activities Assistant's behavior blurred the lines between professional and personal interactions with residents, leading to further emotional harm to Resident #34. In a separate incident, Resident #3, a male with cerebral palsy, experienced verbal and mental abuse by a CNA. The CNA was reported to have yelled at Resident #3, which the resident found abusive and distressing. The Maintenance Director witnessed the incident, and the facility's investigation confirmed the occurrence of verbal abuse. Both incidents highlight the facility's failure to protect residents from abuse and neglect, as well as the lack of effective policies and procedures to prevent such occurrences.

Removal Plan

• Additional training added regarding separation of employees and residents and a healthy, professional boundary.
• Psych services were called.
• MD called.
• Medical director informed.
• Planned call with Resident #34's family member to review final findings of the investigation.
• Ongoing monitoring for resident continues to ensure there are no lasting adverse outcomes related to this incident.
• Counseling as necessary for support services for resident.
• SW and Administrator will continue checking ins.

Penalty

Inspection fine: $16,801

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that all alleged violations involving abuse or neglect were reported to the facility Administrator immediately, as required by their policy. This deficiency was identified in the case of a resident who was verbally abused by the Weekend Activities Assistant at the nurse's station. The incident occurred in front of other residents and staff, but the facility's Abuse Coordinator was not notified immediately, which is a violation of the facility's policy. The resident involved, a female with no cognitive impairment, had a history of anxiety disorder, depression, and psychotic disorder. She reported that the Weekend Activities Assistant yelled at her and touched her leg, which embarrassed her in front of others and caused her emotional distress. The resident's family member confirmed that the resident was very upset and crying over the situation. Despite the resident's clear distress and the presence of witnesses, the incident was not reported to the facility management in a timely manner. Interviews with staff revealed that there was a lack of immediate reporting of the incident to the Administrator. Some staff members, including a CNA and the WCN, acknowledged that they were aware of the requirement to report abuse immediately but failed to do so. The facility's policy on reporting abuse was not followed, leading to a delay in addressing the situation and protecting the resident from further harm.

Penalty

Inspection fine: $16,801

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a nourishing, palatable, well-balanced diet that met the daily nutritional and special dietary needs of its residents, specifically affecting two residents who did not receive milk with their breakfast. Observations revealed that the facility's milk supply was insufficient, with only 12 individual servings available on the morning of the survey. Interviews with residents indicated that they occasionally did not receive milk with their meals, leading to dissatisfaction. The Dietary Aide confirmed that the milk supply was sometimes inadequate, and it was the responsibility of all staff to report low supplies to the Dietary Manager. The Dietary Manager acknowledged the shortage of milk and attributed it to company policy, which restricted milk orders based on census numbers. Despite having the option to order emergency milk deliveries or use powdered milk from the emergency supply, these measures were not utilized in time to prevent the shortage. The Dietary District Manager emphasized the importance of maintaining an adequate milk supply, noting that failure to do so could pose a dignity issue and nutritional risk for residents. The facility's policy required that missing food groups be supplemented, but this was not effectively implemented in this instance.

Penalty

Inspection fine: $16,801

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident, who was unable to perform activities of daily living due to severe cognitive impairment and physical limitations, received necessary services to maintain good grooming and personal hygiene. Specifically, the resident's fingernails were observed to be long and untrimmed, despite the resident expressing a desire for them to be cut. The resident, who had a history of stroke, hemiplegia, and renal insufficiency, required substantial assistance with daily activities as indicated in his care plan. Interviews with facility staff revealed inconsistencies in the provision of nail care. A CNA mentioned that nail care was supposed to be performed as needed and during shower days, but admitted to not having been in-serviced on nail care. An LVN stated that CNAs were responsible for nail care and that she would cut nails if observed to be too long, but had not noticed the resident's nails. The ADON emphasized that nail care was everyone's responsibility and should be documented if refused by a resident. The facility's policy on nail care, dated April 2007, outlined the importance of regular cleaning and trimming to prevent infection, but staff could not recall recent in-service training on this policy.

Penalty

Inspection fine: $16,801

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide respiratory care consistent with professional standards for a resident who required oxygen therapy. The resident, an elderly female with a BIMS score indicating no cognitive impairment, had diagnoses of asthma and chronic obstructive pulmonary disease. Her care plan included the use of oxygen therapy, and the physician's orders specified that the nasal cannula and water humidification should be changed weekly on Sundays during the night shift. However, observations revealed that the nasal cannula had not been changed as per the schedule, with the last change dated over a week prior. Interviews with staff, including LVN X and ADON Z, confirmed that the nasal cannula was not changed on the designated Sunday. LVN X acknowledged the oversight and indicated that the change was typically verified by the ADON on Mondays. ADON Z admitted to being distracted and forgetting to change the nasal cannula, which he believed he had done. The facility's policy on oxygen administration required adherence to physician's orders, but this was not followed, leading to a lapse in infection control practices.

Penalty

Inspection fine: $16,801

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that all drugs and biologicals were stored in locked compartments as required by State and Federal laws. During an observation, a medication cart parked at the nurse's station for the 100 Hall was found unlocked, with all drawers accessible except for the controlled substances drawer. This occurred while five residents were present in the common area around the nurse's station. The incident was linked to LVN C, who had requested MA D to leave the cart open to retrieve something before leaving, but the cart was not locked afterward. Interviews revealed that MA D was unaware that LVN C had not locked the cart after use, and the DON confirmed that all medication carts should be locked when unattended. LVN C could not recall the specific details of the incident, including whether she had asked MA D to leave the cart open or if she had returned to the cart after handing over the keys. The facility's policy on the storage of medications, dated April 2007, mandates that compartments containing drugs and biologicals must be locked when not in use, and carts should not be left unattended if open.

Penalty

Inspection fine: $16,801

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to the prescribed menu for a resident on a pureed diet during a lunch meal. Specifically, the resident, who had a history of dementia, stroke, and hemiplegia, was supposed to receive pureed bread and pureed angel food cake as part of their meal. However, these items were not provided, and the resident received applesauce instead of the cake. This discrepancy was observed during a survey, and it was noted that the test tray provided to the survey team also lacked the pureed bread and cake. Interviews with the Dietary Manager and the District Dietary Manager revealed that the pureed items were prepared but not placed on the trays due to an oversight by the server. The Dietary Manager acknowledged that it was the server's responsibility to ensure all items were included on the trays, while the Cook was responsible for preparing the purees. The absence of these items meant that the resident did not receive the full nutritional value intended by the menu, as confirmed by the District Dietary Manager. The facility's policy on therapeutic diets, which requires adherence to physician-prescribed diets and a tray identification system, was not followed in this instance.

Penalty

Inspection fine: $16,801

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide food prepared in a form designed to meet individual needs for a resident who required a mechanically altered therapeutic diet. Specifically, the facility did not ensure that the pureed carrots served to the resident were free of whole slices, which is a requirement for residents with dysphagia to prevent choking or aspiration. The resident in question was an elderly female with primary diagnoses of dementia, stroke, and hemiplegia, and was unable to complete a Brief Interview for Mental Status (BIMS). Her care plan indicated the need for a dysphagia advanced level 1 texture diet, yet the facility did not adhere to this requirement. Observations and interviews revealed that the pureed carrots contained chunks, which was confirmed by both the Dietary Manager and the Dietary District Manager. They acknowledged that pureed foods should be smooth and that the presence of chunks could pose a choking hazard. The Dietary Manager noted that it was the responsibility of dietary aides and nurses to ensure the correct diet consistency was served, and mentioned that an in-service on preparing pureed foods had been conducted the previous week. The facility's corporate recipe for pureed carrots also specified that the carrots should be blended until smooth, following specific thickener guidelines.

Penalty

Inspection fine: $16,801

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain accurate medical records for a resident, specifically regarding the documentation of oxygen therapy. The resident, an elderly female with a diagnosis of asthma and chronic lung disease, was supposed to have her nasal cannula changed weekly on Sundays. However, the Treatment Administration Record (TAR) inaccurately indicated that the nasal cannula was changed on a specific date, despite observations showing it had not been changed. The resident herself confirmed that the nasal cannula had not been replaced as scheduled. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Interim Director of Nursing (DON), revealed that the staff were aware of the requirement to document treatments accurately. The ADON acknowledged that a check mark on the TAR should only be made if the treatment was completed, and inaccurate documentation could lead to gaps in care. The Interim DON reiterated that staff should not document treatments that were not provided. Despite attempts, the facility was unable to interview the Licensed Vocational Nurse (LVN) responsible for the inaccurate documentation.