Stonegate Nursing and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, patternF600Oct 25, 2024

  Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 2 of 6 residents (Residents #34 and #3) reviewed for abuse. 1. The facility failed to ensure Resident #34 had the right to be free from abuse when she was verbally and mentally abused by the Weekend Activities Assistant on 07/14/24. 2. The facility failed to ensure Resident #3 had the right to be free from abuse when he was verbally and mentally abused by CNA U on 07/08/24. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 07/08/24 and ended on 07/14/24. The facility had corrected the noncompliance before the investigation began. These failures placed residents at risk of abuse, trauma, and psychosocial harm. Findings included: 1. […]

• Immediate jeopardy, patternF607Oct 25, 2024

  Based on observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse and neglect of residents for 2 of 6 residents (Residents #34 and #3) reviewed for abuse. 1. The facility failed to protect Resident #34 from retaliation after the Weekend Activities Assistant was suspended based on an allegation of abuse on 07/14/24. 2. The facility failed to protect Resident #3 from verbal and mental abuse by CNA U on 07/08/24. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 07/08/24 and ended on 07/14/24. […]

• Immediate jeopardy, patternF880Jan 17, 2021

  Based on observation, interview, and record review, the facility failed to maintain an Infection Control Program designed to help prevent the transmission of disease and infection for eight (Residents #3, #4, #5, #6, #7, #8, #9, and #10) of 18 residents reviewed for infection control. CNA B failed accurately report signs and symptoms of COVID-19 she was displaying when screened at the beginning of her shift on 01/10/21 and 01/12/21 and continued work with residents while displaying signs and symptoms of COVID-19. CNA B tested positive for COVID-19 on 01/12/21. The facility failed to determine which residents CNA B interacted with, place those residents in quarantine due to an unknown COVID-19 status, and use appropriate PPE during interactions with those residents. […]

• Immediate jeopardy, isolatedF609Oct 25, 2024

  Based on interview and record review, the facility failed to ensure all alleged violations involving abuse or neglect were reported to the facility Administrator immediately but no later than 2 hours for 1 of 6 residents (Resident #34) reviewed for abuse and neglect. The facility failed to immediately notify their Abuse Coordinator (the Former Administrator) when the Weekend Activities Assistant had yelled at Resident #34 at the nurse's station in front of other residents and staff on 07/14/24. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 07/14/24 and ended on 07/14/24. […]

• Actual harm, isolatedF697Oct 18, 2022

  Based on interview and record review, the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for one of six residents (Resident #1) reviewed for pain management. The facility failed to ensure Resident #1 received medications according to physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure could place residents at risk of unrelieved pain and discomfort. Findings included: Record review of Resident #1's Admission Record, print date 10/18/22, in the EHR revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]