Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Stonewall Living Center during CMS and state inspections, most recent first.
Cell Phone Use During Resident Care: Thirteen confidential residents stated nurses and CNAs used personal cell phones, often with earbuds, while providing care on every shift, including during feeding. The residents said this made them feel ignored, embarrassed, and that their privacy was violated. The ADM and DON stated cell phone use is not acceptable during resident care and that residents should receive privacy and dignity.
Food service staff failed to store multiple items in the refrigerator and freezers with required dates and labels. During a kitchen observation, several foods were found in clear plastic bags that were undated, unlabeled, or had no use-by date, including baked goods, meats, breakfast items, vegetables, and other frozen foods. Interviews showed kitchen staff, the DM, RD, and ADM all identified dating and labeling as a shared responsibility, with the DM responsible for monitoring compliance, and the facility policy required covered food containers to be dated and labeled.
A resident with muscle weakness and difficulty walking, who required a mechanical lift with two staff for transfers, was manually transferred by two CNAs who did not follow the care plan or posted care indicators. During the transfer, the resident's leg gave out, and staff assisted her to the floor. The resident was later found to have sustained a right femur fracture as a result of the incident.
A resident prescribed PRN Methocarbamol for pain management had a significant number of tablets unaccounted for due to inconsistent documentation and lack of medication counts. The facility did not ensure accurate tracking or recording of PRN medication administration, resulting in a discrepancy between the number of pills received and those documented as given. Staff interviews revealed that PRN medications were sometimes not documented, and muscle relaxers were not counted like controlled substances, leading to the deficiency.
The facility failed to inform 7 of 24 residents about the grievance process, including how to file grievances and the option for anonymity. Residents were unaware of where to obtain or submit grievance forms, and there was no visible signage or designated area for these forms. The DON and ADM acknowledged the absence of a system for anonymous grievances and the reliance on verbal communication, which could exclude residents uncomfortable with voicing concerns verbally.
The facility's dietary services failed to follow proper handwashing and glove-changing protocols, as observed with the Dietary Director and a staff member. The Dietary Director used a used paper towel to turn off the water, and a staff member, [NAME] A, did not change gloves after handling potentially contaminated items. Both individuals acknowledged their awareness of the correct procedures but failed to adhere to them, risking food contamination.
Cell Phone Use During Resident Care
Penalty
Summary
The facility failed to treat residents with respect, dignity, privacy, and self-determination by allowing staff to use personal cell phones while providing resident care. Thirteen confidential residents stated that nurses and CNAs used cell phones during care on every shift, including while feeding residents during meals, and that the use of earbuds was common. The residents said this made them feel ignored, not a priority, embarrassed, and concerned that staff could make mistakes because of distraction. They also stated that their privacy was violated and that they did not know the names of the staff members involved because the behavior occurred so often. During interviews, the ADM and DON stated that residents should receive privacy during care and that cell phone use is not acceptable while performing resident care. They stated staff were trained on resident rights, dignity, privacy, and cell phone use during orientation, quarterly education, and in-services, and that cell phones should not be used in resident rooms, hallways, or at the nurses' station. The record review of the facility policy on Resident Rights stated that employees shall treat all residents with kindness, respect, and dignity and that residents have the right to a dignified existence and privacy and confidentiality.
Food items found undated and unlabeled in refrigerator and freezers
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in its kitchen. During a kitchen tour, the reach-in refrigerator contained items such as pecan pie, chocolate cake, and a cake in clear plastic bags that were undated, unlabeled, or had no use-by date. Five reach-in freezers also contained multiple food items in clear plastic bags that were undated, unlabeled, or had no use-by date, including sausages, hamburger patties, hot dogs, cookies, omelets, french fries, waffles, pancakes, chocolate chips, diced onion, sweet potatoes, corn flakes, Italian style vegetable, organic multicolor rice, cauliflower, purple onion, and beef. During interviews, the DM stated that kitchen staff were responsible for dating and labeling food items and that she was responsible for monitoring this task, but said the kitchen was short staffed and staff were focused on unloading the truck, cooking breakfast, and serving residents. The A stated that everyone in the kitchen was responsible for dating and labeling food items and that the DM was responsible for monitoring it. The RD stated that all kitchen staff were responsible for dating and labeling food items and that the DM should monitor this on a daily shift. The ADM stated that all kitchen staff were responsible for ensuring food was stored and dated properly and that the DM was responsible for monitoring labeling and dating. The facility policy titled Food Storage required food to be stored in a properly covered container with a date and label identifying what was in the container, and identified acceptable expiration date terms for cold food products.
Failure to Use Mechanical Lift Results in Resident Fracture During Transfer
Penalty
Summary
A deficiency occurred when two CNAs failed to follow the care plan for a resident who required a mechanical lift with two staff for transfers due to muscle weakness, difficulty walking, and congestive heart failure. Instead, the CNAs attempted a two-person manual transfer from the bed to a shower chair, despite clear care indicators posted outside the resident's door and documented in the care plan. During the transfer, the resident's right leg gave out, and the CNAs, along with a family member present, assisted the resident to the floor. The mechanical lift was not used until after the resident was already on the floor. The incident was witnessed by a family member, and both CNAs later stated in interviews that they did not check the care indicators or the resident's care plan before proceeding with the transfer. Both CNAs acknowledged they had been trained on the facility's transfer protocols and the use of mechanical lifts, and that there was no reason to deviate from the prescribed method. The resident was subsequently assessed by nursing staff and transported to the hospital, where imaging revealed an acute traumatic fracture of the right distal femur. Facility records confirmed that the care plan and care indicators had been in place and that staff had been inserviced on their use prior to the incident. Interviews with administrative and nursing leadership confirmed that the expectation was for staff to follow the care plan and posted indicators for all transfers. The failure to use the mechanical lift as required directly led to the resident sustaining a significant injury during the transfer.
Failure to Account for and Document PRN Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for a resident prescribed Methocarbamol 500 mg as a PRN medication for pain management. Over a period of several months, there was a significant discrepancy between the number of Methocarbamol tablets received from the pharmacy and the number documented as administered in the Medication Administration Records (MARs). Specifically, the records showed that far fewer doses were documented as given than the number of tablets supplied, resulting in a large number of pills unaccounted for. The resident involved had a history of dementia and pain in the left knee, and was cognitively intact according to assessment. The resident reported receiving medications as needed and did not experience any instances where medication was unavailable or pain was uncontrolled. However, the facility's documentation practices were inconsistent, with staff interviews revealing that PRN medications were sometimes administered but not always documented. The issue was identified when the pharmacy consultant noted that a refill request for the muscle relaxer was made earlier than expected, prompting a review that uncovered the missing documentation and unaccounted pills. Interviews with facility staff, including the DON, ADM, and several nurses, confirmed that muscle relaxers were not routinely counted or tracked like controlled substances, and that there was a lack of consistent documentation for PRN medication administration. The discrepancy was attributed by facility leadership to documentation errors, but there was no direct evidence to confirm whether the medication was actually administered or diverted. The facility's policies required accurate documentation and secure storage of medications, but these procedures were not followed in this instance, leading to the deficiency.
Failure to Inform Residents of Grievance Process
Penalty
Summary
The facility failed to provide information to residents and their representatives regarding their rights related to filing grievances or concerns. This deficiency was identified for 7 out of 24 confidential residents. During a Resident Council meeting, these residents reported that they were unaware of the grievance process, did not know where to obtain or submit a grievance form, and were not informed about the possibility of filing grievances anonymously. Additionally, they had not observed any postings of the grievance procedure in prominent locations within the facility. Observations and interviews revealed that there was no visible signage or designated area for grievance forms, and the Director of Nursing (DON) was unable to locate blank grievance forms or identify where residents could submit anonymous grievances. The DON acknowledged that there was no previous system in place for filing anonymous grievances and that grievance forms, which were once available near the foyer, had been moved without her knowledge of when or why. The Activities Director (AD) also confirmed the lack of a process for anonymous grievances and was unsure of the location of grievance forms. The Administrator (ADM) stated that grievance forms had been available at the front of the facility but had been moved at some point. The ADM admitted that the previous system relied mostly on verbal communication, which could exclude residents uncomfortable with voicing grievances verbally. The ADM emphasized that it was her responsibility to ensure grievances were resolved, but acknowledged that without a written process, some concerns might go unnoticed and unresolved.
Failure to Follow Handwashing and Glove Protocols in Dietary Services
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the dietary services department. The Dietary Director and a staff member, referred to as [NAME] A, did not follow proper handwashing and glove-changing protocols. Specifically, the Dietary Director was observed using a used paper towel to turn off the water after washing her hands, which is against the facility's policy. Similarly, [NAME] A was observed turning off the water with bare hands after washing and failing to change gloves after picking up a piece of paper from the floor and handling food. Additionally, [NAME] A was seen carrying a pan to the dishwashing area and returning to the food prep area without changing gloves or washing hands. Interviews with [NAME] A and the Dietary Director revealed that both were aware of the proper procedures but failed to follow them due to nervousness and oversight. The facility's policies, dated March 2021, clearly outline the necessity of using a clean paper towel to turn off the water and changing gloves after leaving the food prep area. The Dietary Director acknowledged her responsibility, along with the shift leader, to monitor staff compliance with these procedures. The ADM also confirmed that the Dietary Director was responsible for ensuring all kitchen staff adhered to handwashing and glove usage policies.
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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 Aspermont
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Homeplace Manor Healthcare Center | 19.7 mi | ★★★★★ | 25 | 0 |
| Kent County Nursing Home | 21 mi | ★★★★★ | 4 | 0 |
| Avir At Haskell | 28 mi | ★★★★★ | 0 | 0 |
| Harmony Care At Stamford | 29.8 mi | ★★★★★ | 0 | 0 |
| Avir At Knox City | 30.1 mi | ★★★★★ | 12 | 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.