Nightingale at Stonegate

In the surveyor’s words

From the most serious findings on record at Nightingale at Stonegate, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Dec 3, 2021

  Based on observation and interview, the facility failed to ensure dietary staff used clean dish-handling practices during meal service to prevent potential contamination that could result in food borne illness for residents who received meals from 1 of 1 kitchen. The findings are: On 11/29/21 at 12:15 PM, while on the serving line, with no gloves on, Dietary Employee #1 removed a clean plate from the cart, touching the interior surfaces of the clean plate with her fingers prior to placing a serving of chicken on the plate. She then passed the plate to the next person on the serving line. She proceeded to remove another plate from the cart, touching the interior surfaces of the plate with her fingers and she placed chicken on the plate. a. […]

• No harm, potential for more than minimal, patternF921Jul 24, 2025

  Based on observation, interview, record, and facility policy review, the facility failed to ensure housekeeping and maintenance provided a safe, sanitary, comfortable environment for the residents who reside in the facility. This failed practice has the potential to affect 38 of 59 residents living in the facility. The findings include: Halls 100 and 300 During an observation on 07/21/2025 at 2:17 PM, in the Shower Room on the 300 hall, it was observed to have dried, brown substance and a black ring around in the toilet bowl; the smaller shower chair had clusters of black spots on all four legs, the back of the chair, under the chair and on the back mesh of the seat. Orange, brown, and white residue noted on the mesh of the seat. […]

• No harm, potential for more than minimal, patternF550Apr 12, 2024

  Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity, and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 3 (Residents #7, #10, #50) sampled residents. The findings are: 1. Resident #7 had diagnoses of Intervertebral disc degeneration lumbar region and Gastro-esophageal reflux disease. According to a Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/18/2024, Resident #7 scored 09 (8-12 indicates moderately impaired cognition) on a Brief Interview of Mental Status (BIMS). The care plan documented that Resident #7 needed assistance with spoon feeding for all meals. […]

• No harm, potential for more than minimal, patternF657Apr 12, 2024

  Based on interview and record review, the facility failed to ensure care plans were reviewed and revised at least quarterly and/or when residents' care needs changed, as evidence by failure to revise the plan of care to address an indwelling urinary catheter and dementia care, to ensure staff were aware of the necessary care, assessments and services required for 1 (Resident #15) of 1 sampled resident who had an indwelling catheter and 1 (Resident #6) of 3 sampled residents whose care plans were reviewed for dementia care. The findings are: 1. Resident #6 had a diagnosis of dementia as documented in an Order Summary Report. a. […]

• No harm, potential for more than minimal, patternF812Apr 12, 2024

  Based on observation and interview, the facility failed to ensure food items stored in the refrigerator and freezer were covered, sealed and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; 1 of 1 ice machine was maintained in clean and sanitary condition to prevent contamination of airborne particles; baseboard was secured, wall were free of chips, stains and rust and were maintained in clean sanitary conditions, and dietary staff. washed their hands before handling clean. equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen; These failed practices had the potential to affect 55 residents who received. meals from the kitchen, (total census: 56). The findings are: 1. […]