Life Care Center of Stonegate

In the surveyor’s words

From the most serious findings on record at Life Care Center of Stonegate, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 25, 2025

  Based on observations, record review and interviews, the facility failed to ensure two (#2 and #4) three residents reviewed for accidents and hazards received adequate supervision to prevent accidents out of four sample residents.Resident #2, who had severe cognitive impairment, was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, a right ankle fracture and right shoulder ligament repair following a fall at home. The resident's right ankle was immobilized in an orthopedic boot and her right arm was immobilized in a sling. The facility identified upon admission that the resident was a high risk for falling and initiated a baseline fall care plan. However, the baseline fall care plan failed to include interventions to prevent falls for the resident. […]

• Actual harm, isolatedF760Oct 3, 2024

  Based on record review and interviews, the facility failed to ensure one (#287) of five residents out of 35 sample residents was free from significant medication errors. Resident #287 was admitted to the facility on [DATE] for skilled nursing care after a failed left total knee revision. Secondary diagnoses included hypertension (high blood pressure), post-procedural pain and a history of heart failure. Resident #287's physician's orders for medications, upon his admission to the facility from the hospital on 6/20/24, included an order for carvedilol (a medication used to treat high blood pressure and heart failure) 6.25 milligrams (mg) twice daily for heart rate and blood pressure (BP). The hospital's list of physician ordered medications was verified by the facility's physician. […]

• No harm, potential for more than minimal, patternF561Oct 3, 2024

  Based on record review and interviews, the facility failed to honor resident choices for four (#71, #130, #183, and #186) of eight residents reviewed for self-determination out of 35 sample residents. Specifically, the facility failed to provide bathing for Resident #71, #130, #183 and #186 per their preferences. Findings include: I. Facility policy and procedure The Activities of Daily Living (ADL) policy, reviewed 9/10/24, was provided by the nursing home administrator (NHA) on 10/9/24 at 4:13 p.m. It read in pertinent part, The resident will receive assistance as needed to complete activities of daily living (ADLs). The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living: bathing, dressing, grooming, and oral care. […]

• No harm, potential for more than minimal, patternF684Oct 3, 2024

  Based on observations, record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for three ( #181, #177 and #240) of nine residents reviewed out of 35 sample residents. Specifically, the facility failed to: -Ensure Resident #181 and Resident #177 received skin care as ordered by the physician; and, -Ensure Resident #240's provider was notified timely of a delay in starting antibiotics and ensure the resident's vital signs were monitored during a change in condition. Findings include: I. Failure to ensure Resident #181 and Resident #177 received skin care as ordered by the physician A. […]

• No harm, potential for more than minimal, patternF686Oct 3, 2024

  Based on observations, record review and interviews the facility failed to ensure eight (#239, #59, #232, #231, #183, #23, #36, #21) of 12 residents out of 35 sample residents received the necessary treatment and services according to professional standards of practice to prevent or heal pressure injuries. Specifically, the facility failed to: -Ensure timely and accurate skin assessments were conducted and interventions were in place to prevent Resident #239 from developing a facility-acquired unstageable coccyx wound; -Ensure Resident #59, who was at risk for developing pressure wounds, had effective personalized preventative measures in place, accurately documented a pressure wound and was provided pressure ulcer treatment per physician orders; -Ensure Resident #232, who was admitted… […]