Stonewall Living Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jun 19, 2025

  Based on observation, interview and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 7 residents (Resident #1) reviewed for accidents. The facility failed to ensure CNA A and CNA B implemented the appropriate amount of assistance when they transferred Resident #1 themselves instead of using a mechanical lift, as was care planned. The Failure resulted in staff having to assist Resident #1 to the flor, and required her to be sent to the hospital where she was ultimately diagnosed with a fractured right femur. The noncompliance was identified as PNC. The IJ began on 06/14/25 and ended on 6/17/25. […]

• No harm, potential for more than minimal, widespreadF812Oct 12, 2023

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: 1) The facility failed to ensure foods were processed and pureed under sanitary conditions. 2) The facility failed to ensure dietary staff ensured food and non-food contact surfaces were clean. and 3) The facility failed to ensure foods were stored in a manner to prevent contamination. These failures could place residents at risk for food contamination and foodborne illness. […]

• No harm, potential for more than minimal, widespreadF801Jun 10, 2021

  Based on interview and record review the facility failed to designate a person to serve as the director of food and nutrition services who met the required qualifications for 29 of 29 residents who consumed food orally. 1)The facility failed to designate a person to serve as the director of food and nutrition services who met federal and state specific Dietary Manager requirements. This failure could place residents at risk to the spread of foodborne illness and residents not having their nutritional need met. The findings include: Record review of the personnel file for the dietary manager revealed that she had a date of hire of 6/24/10. […]

• No harm, potential for more than minimal, widespreadF804Jun 10, 2021

  Based on observation, interview and record review the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive and at a safe and appetizing temperature for 29 of 29 residents who consumed foods orally. 1. The facility failed to ensure foods were served which were palatable and at an appetizing temperature for residents. These failures could place residents at risk of decreased food intake and unwanted weight loss. The findings include: On 06/08/21 at 03:19 PM In a confidential resident group meeting in the dining room the residents were asked to rate the food palatability/taste satisfaction of their meals over the last three to four weeks on scale of one to ten from bad to excellent taste. […]

• No harm, potential for more than minimal, widespreadF812Jun 10, 2021

  Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 29 of 29 residents who consumed food from the facility's only kitchen; in that: 1) Dietary staff (staff A and D) failed to ensure foods were protected from possible contamination during processing and allowed to air dry (puree processing, dishware). 2) In use foods were expired and not in sound condition (moldy/rotting celery and jalapenos and expired packets of sliced ham and turkey breast). […]