Stonegates

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Dec 5, 2023

  Revised post IDR Based on interview and record review, it was determined that for two (R14 and R38) out of two residents reviewed for accidents, the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents. R14, a cognitively impaired resident with dementia and identified as high risk for wandering, eloped from the building on 2/18/23 and was found outside on the community grounds by a bystander. R14 was at risk of a severe adverse outcome. An IJ (immediate jeopardy) was identified on 12/4/23 at 2:17 PM and abated on 12/4/23 at 11:59 PM. […]

• No harm, potential for more than minimal, widespreadF812Dec 6, 2024

  Based on observation and interview it was determined that the facility failed to ensure food was stored, prepared and served in a manner that prevents food borne illness to the residents. Findings include: 12/3/24 9:30 AM - Observations in the kitchen: - The walk-in refrigerator had opened food items stored in facility containers labeled and dated as follows: tartar 10/8/24, mandarins 11/23/24, and cherries 11/18/24. There were no dates to indicate when it should be consumed, sold or discarded. In addition, bread slices and sesame buns located inside did not include any dates. The dry storage area contained a bag of tortilla chips, a bag of grits, and a pan of almonds that were not dated when they were opened or prepared. […]

• No harm, potential for more than minimal, widespreadF880Dec 6, 2024

  Based on observation and interview it was determined that for two random observations of the laundry room, the facility failed to handle, store and process linens to prevent the spread of infection. 12/4/24 9:30 AM - The following was observed in the laundry area: - The door from the washer room to the dryer (clean) room was open. -The room with the washing machines had blue rags on the floor to the right of the washer and a cell phone was plugged in and laying on top of a washer. -The soiled room contained an office desk, resident emergency water supply, a cell phone on the desk and a cart with clean linen that had a cover on it. 12/4/24 9:35 AM - In an interview E16 (Laundress) confirmed the door was open. […]

• No harm, potential for more than minimal, patternF947Dec 5, 2023

  Based on record review and interview, it was determined that for four (E13, E21, E26 and E27) out of seven Certified Nursing Assistants (CNAs) reviewed for in-service education, the facility failed to ensure each CNA received at least twelve hours of in-service training per year. Findings included: 1. E13 had a hire date of 11/21/22. A course transcript list was not available. Review of her course certificate of completion on abuse, neglect and exploitation was dated 12/1/23 and revealed she received 0.75 hours of in-service training. E2 verified E13 had not received 12 hours of in-service training in the last year of her employment. 2. E21 had a hire date of 11/3/22. Review of her course transcript list revealed 8.5 hours of in-service training. […]

• No harm, potential for more than minimal, isolatedF641Dec 12, 2025

  Based on record review and interview, it was determined that for two (R18 and R27) out of three residents reviewed for accidents, the facility failed to accurately reflect R18 and R27's status by documenting their medication, carbidopa-levodopa, as an anticonvulsant. Findings include: 1. Review of R18's clinical record revealed: 11/3/23 - R18 was admitted to the facility with diagnosis including but was not limited to, Parkinson's disease.11/3/23 - E9 (MD) ordered in R18's EMR, carbidopa-levodopa oral tablet 25-100 mg - give 1.5 tablet by mouth three times a day for Parkinsons.9/20/25 - R18's annual MDS (Minimum Data Set) documented that R18 was taking an anti-convulsant.12/1/25 - R18's significant change MDS documented that R18 was taking an anti-convulsant.12/9/25 1:30 PM - A review of… […]