Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Stonemere Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found an unattended, unlocked medication cart on a resident hall with a drawer open and medications accessible while no nurse or med aide was nearby. Various staff walked past the unsecured cart before an RN returned and acknowledged it was his cart, confirmed it had been left unlocked, and stated it should have been locked with narcotics under double lock. The DON reported that carts must be locked or within the nurse’s line of sight and that leaving them open allows anyone, including residents or confused individuals, to access medications, contrary to the facility’s written medication storage policy.
A resident with dementia, acute kidney failure, and type 2 DM received blood glucose monitoring and insulin from an RN who did not follow infection control procedures. The RN placed a glucometer on an unsanitized med cart and on a tissue on the overbed table instead of a properly cleaned surface, and returned the used glucometer to the unsanitized cart. The RN then prepared and administered insulin using an insulin pen without wearing gloves, handled the pen and the resident’s skin with bare hands, and placed the used pen back on the unsanitized cart. These actions did not comply with facility policies requiring standard precautions, glove use, and proper cleaning and disinfection of equipment between uses.
A resident with a history of dysphagia and severe cognitive impairment choked during a meal and later died. Despite staff attempts to assist, the facility failed to report the incident to the State Survey Agency, as required by policy. The resident was known to be at risk for choking, and staff were instructed to remain with her during meals. The facility's DON and Administrator did not suspect neglect and chose not to report the incident.
The facility failed to maintain a safe and functional environment in 10 resident bathrooms, where rubber shower dams were not properly glued down, posing a trip hazard. Staff were unaware of the issue, and it was not logged in the Maintenance Logbook, despite the facility's policy to identify and address hazards.
A facility failed to ensure proper use of physical restraints for a resident by not obtaining consent, a physician's order, or updating the care plan for full bed rails. The resident, with a history of falls and dementia, had full side rails implemented at the family's insistence, contrary to facility policy.
The facility failed to ensure that insulin pens in the 200 Hall Nursing Cart were labeled with open dates for four residents. This oversight was confirmed by an LVN and the DON, who stated that nursing staff are required to check their carts daily and discard insulin after 28 days. The absence of open dates could lead to the use of expired insulin, posing a risk to residents' health.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety. Observations revealed dust and dirt on kitchen equipment, including the ice machine, insulated coolant hose, and free-standing fans. Interviews confirmed that the equipment should be kept clean to prevent contamination. Record reviews indicated that the cleaning schedule did not include the walk-in cooler and dry storage areas, leading to the observed deficiencies.
The facility failed to properly dispose of garbage and refuse, leading to an unsanitary trash corral area with litter and broken furniture. The Dietary Manager, Maintenance Director, and Administrator acknowledged the issue, citing a lack of formal training and storage space as contributing factors.
The facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days or had documented rationale for extension. Two residents had active PRN orders for Lorazepam without an end date, placing them at risk of unnecessary medication use.
The facility failed to ensure the call light system in a resident's room was functioning properly, despite multiple attempts to fix it and daily rounds intended to identify such issues. The malfunction persisted, leaving the resident unable to effectively call for assistance.
Unattended Unlocked Medication Cart on Resident Hall
Penalty
Summary
The deficiency involves failure to ensure medications were stored securely and inaccessible to unauthorized individuals, as required by facility policy and professional standards. During observation on Hall 200, a medication cart was found unlocked with a drawer pulled open, and no nurse or medication aide present nearby. The investigator was able to walk around the cart and access medications, while housekeeping staff, a hospice aide, and a wound care nurse were observed walking past the unsecured cart. The cart was identified as belonging to an RN who had been administering medications on the hall. When interviewed and shown the cart, the RN confirmed that the cart was his, acknowledged that it had been left unlocked with drawers open, and stated he could not explain why it had been left unattended in that condition. He stated the cart should have been locked at all times and that narcotics were to be under double lock, and acknowledged there was a risk of residents taking medications from the cart. The DON later stated that medication carts should be locked at all times or within the nurse’s or medication aide’s direct line of sight, and confirmed that leaving a cart unlocked and unattended allowed anyone, including other staff, residents, or confused individuals, to reach into the cart and remove medications. Review of the facility’s Storage of Medications policy showed that all drug storage compartments, including carts, must be locked when not in use and not left unattended if open, and that only authorized personnel may have access to medications.
Improper Infection Control During Glucose Monitoring and Insulin Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain proper infection prevention and control practices during blood glucose monitoring and insulin administration for one resident. The resident was an older male with dementia, dysphagia, acute kidney failure, and type 2 DM who had orders for scheduled and sliding-scale insulin. During observation, RN A’s glucometer was seen resting on top of an unsanitized medication cart on a stack of handwritten papers before use. RN A then took the glucometer, test strip, alcohol pads, lancet, and tissues into the resident’s room, placed a tissue on the overbed table, and set the glucometer on the tissue rather than on a sanitized surface. After obtaining the blood glucose reading, RN A returned the used glucometer to the top of the medication cart, again placing it on the handwritten papers without cleaning the cart surface. The report further describes that RN A prepared and administered insulin without following required glove use and aseptic technique. After obtaining the blood glucose result, RN A removed the insulin pen from the cart and cleaned the top of the insulin pen with an alcohol swab without wearing gloves. RN A then entered the resident’s room, assisted with raising the resident’s gown, primed the insulin pen, and cleaned the resident’s abdominal skin with an alcohol swab using bare hands. RN A administered the subcutaneous insulin injection into the resident’s abdomen without wearing gloves and then returned the soiled insulin pen to the top of the unsanitized medication cart before washing hands in the bathroom. Interviews and policy review confirmed that these actions did not follow the facility’s infection control procedures. RN A acknowledged not cleaning the top of the medication cart, stated there was a three-minute kill time for the germicidal product, and admitted that gloves should have been worn while preparing the insulin pen and administering the insulin to reduce the spread of possible infections. The DON stated that glucometers were to be cleaned before and after use, that supplies should be taken into the room and the glucometer placed in a designated dirty area on the cart (such as a wash basin or wax paper) rather than directly on the cart, and that the entire process, including skin preparation and injection, should be completed while wearing gloves. Facility policies on infection control and obtaining fingerstick glucose levels required standard precautions, hand hygiene, glove use, and cleaning and disinfecting reusable equipment between uses, which were not followed in this incident.
Failure to Report Resident Choking Incident
Penalty
Summary
The facility failed to report an incident involving a resident who died after a choking episode in the dining room to the State Survey Agency. The resident, who had a history of stroke, dysphagia, and severe cognitive impairment, was on a mechanically altered diet and required assistance with eating. Despite these precautions, the resident choked during a meal, and the Heimlich maneuver was unsuccessfully attempted by staff. The resident was a DNR, and after being moved to her room, she was pronounced dead by paramedics. Interviews with staff revealed that the resident was known to be at risk for choking and aspiration, and staff were instructed to remain with her during meals. On the day of the incident, the resident was being fed by a CNA when she began to cough. The CNA called for help, and an LVN attempted the Heimlich maneuver. Despite efforts by multiple staff members, the resident was unable to be revived. The facility's DON and Administrator were informed of the incident, but they did not report it to the State, as they did not suspect neglect or foul play. The facility's policy requires immediate reporting of alleged violations involving abuse, neglect, or mistreatment, but the Administrator and DON determined that the incident did not warrant reporting. The facility's failure to report the incident could place residents at risk of neglect, as it did not comply with federal and state reporting requirements. The facility's policy outlines the responsibilities of the Administrator, DON, and Risk Manager in investigating and reporting such incidents, but these procedures were not followed in this case.
Failure to Maintain Safe and Functional Resident Bathrooms
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents in 10 of 62 resident bathrooms reviewed. Specifically, the rubber shower dams in rooms #108, #117, #118, #120, #121, #218, #224, #227, #231, and #238 were not properly glued down, posing a trip hazard. Observations revealed that the rubber shower dams were only attached at the ends, with the glue in the middle having failed, allowing the rubber strip to move two to three inches in each direction. This issue was noted during observations on two separate days. Interviews with residents indicated that they had not noticed the loose rubber dams but acknowledged that they could pose a tripping hazard. Staff members, including the Assistant Director of Nursing (ADON), Maintenance Director, Housekeeping Director, and other management staff, were unaware of the issue. The Maintenance Director admitted to having ongoing problems with securing the shower dams and noted that staff sometimes used the showers before the glue had dried, despite posted signs. The Maintenance Logbook showed no record of the issue being reported between 12/19/2023 and 03/05/2024. The facility had a policy in place to identify and address hazardous areas, devices, and equipment to ensure resident safety. However, the policy was not effectively implemented, as evidenced by the failure to log the maintenance issue and the lack of awareness among staff conducting Concierge Rounds. The Administrator and other staff members confirmed that the loose rubber dams posed a safety risk, but the issue had not been identified or addressed in a timely manner.
Failure to Ensure Proper Use of Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints unless required for medical treatment. Specifically, the facility did not obtain consent, a physician's order, or include the use of full bed rails in the care plan for a resident. The resident, who had a history of repeated falls, legal blindness, muscle wasting, lack of coordination, and dementia, was observed with full side rails on both sides of the bed, which restricted his movements. The family had insisted on the use of full side rails to prevent falls, despite the facility's policy against such use without proper documentation and consent. The resident's care plan initially included the use of 1/4 side rails as an enabler per family request, but there was no documentation or care plan update to reflect the use of full side rails. Interviews with staff revealed that the resident required total assistance with activities of daily living and was at high risk for falls. However, there was no physician's order or care plan for the full side rails, and the staff were unaware of when the full side rails were implemented. The Director of Nursing (DON) acknowledged the lack of proper documentation and stated that the family had been informed of the risks associated with full side rails. The facility's policy on the use of restraints clearly stated that restraints should only be used for the safety and well-being of the resident and only after other alternatives had been tried unsuccessfully. The policy also required written orders from a physician and consent from the resident or their representative. The failure to follow these procedures resulted in the use of full side rails without proper documentation, potentially putting the resident at risk of unnecessary restriction of movement and other complications.
Failure to Properly Label and Store Insulin Pens
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with currently accepted professional principles and stored under proper temperature controls. Specifically, the 200 Hall Nursing Cart contained in-use insulin pens for four residents without open dates. This failure was observed during an inventory check by LVN P, who confirmed that the insulin pens for Residents #1, #8, #13, and #57 were not labeled with open dates. LVN P stated that nursing staff are expected to check their carts daily for inappropriately labeled medications and that insulin must be labeled with the date opened to track the expiration date. The absence of open dates on the insulin pens could lead to the use of expired insulin, which may be less effective and pose a risk to residents' health. The Director of Nursing (DON) confirmed that nursing staff are required to check their carts daily at the beginning of their shift to ensure there are no expired medications and that insulin should be dated and discarded after 28 days. The DON also mentioned that the Assistant Director of Nursing (ADON) and DON are responsible for monitoring the carts and performing audits every other week, although there was no documentation of these audits. The facility's policy on the storage of medications states that discontinued, outdated, or deteriorated drugs should not be used and must be returned to the dispensing pharmacy or destroyed.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. Observations revealed that the vents on both sides of the ice machine were covered with black dust and fuzz, posing a risk of contamination to the food preparation area and drink dispenser. Additionally, the insulated coolant hose in the walk-in cooler was covered in thick, moist black dirt and fuzz, directly above food stored on shelves. In the dry food storage room, dust and food particles were observed on the lids of bins containing cornmeal, breadcrumbs, and brown sugar. Free-standing fans in the kitchen had a buildup of dust and fuzz on the blades and blade cages, which could potentially contaminate food when in use. The coffee maker also had a vent covered with black sticky fuzz, and a measuring cup was found stored in a bin containing rice, posing a risk of food contamination. Interviews with the Dietary Manager, Corporate Dietician, Administrator, and Director of Nursing (DON) confirmed that the kitchen equipment should be kept clean and food should be stored appropriately to prevent contamination and food-borne illness. The Dietary Manager acknowledged that the black dust buildup on the insulated coolant hose in the walk-in cooler posed a risk of food contamination. He also stated that the lids on the bins containing breadcrumbs, brown sugar, and cornmeal should be kept clean to prevent contamination. The free-standing fans and the vent on the coffee maker should be free of dust to prevent airborne contaminants from getting into the food. The measuring cup stored in the rice bin was also identified as a potential contamination risk. Record reviews indicated that the facility's cleaning schedule did not include the cleaning of the walk-in cooler and dry storage areas. The facility's policy on recommended storage practices emphasized the importance of keeping shelving and floors clean and dry, scheduling regular cleaning of storage rooms, and not storing scoops in food containers. The Federal Drug Administration Food Code also highlighted the need for equipment food-contact surfaces and non-food-contact surfaces to be clean and free of dust, dirt, food residue, and other debris. The facility's failure to adhere to these standards and policies resulted in the observed deficiencies, placing residents at risk for food contamination and food-borne illness.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to dispose of garbage and refuse properly, as observed on 03/05/2024 at 8:45 AM. The trash corral gate was open, and although the trash bin was closed, the area was littered with trash and broken furniture, including rubber gloves, plastic cups, bottles, food wrappers, food waste, wheelchairs, and reclining chairs. The Dietary Manager acknowledged that the corral gate should be closed and free of trash to prevent attracting pests and rodents. He mentioned that the bins were used by all facility departments and believed that he, along with the Housekeeping and Maintenance Directors, were responsible for ensuring the trash area was clean. However, he was unsure if other department heads trained their staff similarly. The Maintenance Director confirmed that the trash corral gates should be closed and noted the presence of spilled food, trash, and broken furniture. He mentioned that the facility had a shortage of storage, leading staff to place broken furniture and equipment in the corral. He did not keep a log of power washing but stated that both maintenance and kitchen staff alternated this task. The Administrator stated that all staff were responsible for keeping the trash bins and corral clean and free of debris, although no written in-service had been conducted. The DON did not follow up on trash disposal issues but expected anyone placing trash in the bins to ensure the area was tidy and secure. The facility's policy indicated that the Maintenance Department was responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times.
Failure to Limit PRN Orders for Psychotropic Drugs
Penalty
Summary
The facility failed to ensure residents did not receive psychotropic drugs pursuant to a PRN order unless the medication was necessary to treat a diagnosed specific condition documented in the clinical record. Additionally, PRN orders for psychotropic drugs were not limited to 14 days, nor was there documentation from the attending physician or prescribing practitioner to extend the PRN order beyond 14 days. This deficiency was observed in two residents who had active PRN orders for Lorazepam without an end date, placing them at risk of receiving unnecessary psychotropic medications. Resident #15, a female with severe cognitive impairment and multiple diagnoses including anxiety and dysphagia, had an active PRN order for Lorazepam starting on 11/16/23 without an end date. Similarly, Resident #75, a female with severe cognitive impairment and multiple diagnoses including hemiplegia and Type 2 diabetes, had an active PRN order for Lorazepam starting on 12/15/23 without an end date. The Director of Nursing (DON) acknowledged the oversight and stated that she was responsible for ensuring PRN antipsychotic medications were addressed timely but had missed these cases.
Failure to Maintain Functional Call Light System
Penalty
Summary
The facility failed to ensure that the call light system in room 233 was functioning properly. During an observation, the surveyor noted that while the call button inside the room activated the red light within the room, the corresponding light outside the room did not illuminate. This issue was confirmed by the resident, who reported that the call light had been non-functional for several days and that no staff had been informed of the problem. Both LVN A and ADON B verified the malfunction and acknowledged the importance of a working call light system for resident safety and assistance. The Maintenance Director admitted to ongoing issues with the call light system and difficulties in sourcing replacement parts. Despite multiple attempts to fix the problem, including replacing the fixture and bulbs, the issue persisted. The Maintenance Director also noted that he conducted random checks on call lights every two weeks but had not been able to resolve the problem in room 233. The Administrator and Executive Assistant were unaware of the issue, despite daily Concierge Rounds intended to identify such problems. The facility's Maintenance Logbook showed multiple entries regarding the call light issue in room 233, but not all entries were initialed, indicating incomplete follow-up. The facility's policy on maintenance service emphasized the importance of maintaining all equipment in a safe and operable manner, but this was not achieved in this instance.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Victoria Gardens Of Frisco | 1.7 mi | ★★★★★ | 2 | 0 |
| The Legacy At Willow Bend | 3.2 mi | ★★★★★ | 4 | 0 |
| Baybrooke Village Care And Rehab Center | 4.1 mi | ★★★★★ | 20 | 0 |
| The Belmont At Twin Creeks | 5.6 mi | ★★★★★ | 6 | 0 |
| Life Care Center Of Plano | 6.2 mi | ★★★★★ | 2 | 0 |
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