Deficiencies (last 4 years)
Deficiencies (over 4 years)
8.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
151% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Feb 20, 2025
Visit Reason
The inspection was conducted based on complaints regarding the facility's failure to reasonably accommodate resident needs and preferences, specifically related to call light accessibility for Resident #3, and concerns about pharmaceutical services including accurate narcotic counts and documentation for Residents #1 and #2.
Complaint Details
The complaint investigation found substantiated deficiencies related to call light accessibility for Resident #3 and pharmaceutical service failures including inaccurate narcotic counts and incomplete documentation for Residents #1 and #2.
Findings
The facility failed to ensure Resident #3 had access to his call light, placing residents at risk of not being able to call for help. Additionally, the facility failed to maintain accurate narcotic counts and proper documentation for Residents #1 and #2, risking medication errors and drug diversion.
Deficiencies (3)
Failed to ensure Resident #3 had access to his call light, which was clipped away from reach.
Failed to provide accurate narcotic counts for Residents #1 and #2 on the 200 Hall medication cart.
Failed to ensure proper documentation and signing off on narcotic administration by RN A.
Report Facts
Narcotic pill count discrepancy: 1
Narcotic pill count discrepancy: 1
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in medication administration and narcotic documentation deficiency. |
| CNA B | Certified Nursing Assistant | Assigned to Resident #3 and involved in call light accessibility issue. |
| DON | Director of Nursing | Provided expectations and training related to call light and narcotic administration. |
| ADON | Assistant Director of Nursing | Provided expectations regarding narcotic medication documentation and audits. |
Inspection Report
Routine
Deficiencies: 2
Date: Jan 3, 2025
Visit Reason
The inspection was conducted to assess compliance with regulations regarding medication storage and food service safety at Stonegate Nursing and Rehabilitation.
Findings
The facility failed to secure medications properly by leaving medication carts unlocked and medications unattended on the nurses' station counter, risking drug diversion. Additionally, the facility failed to check food temperatures on the steam table before serving, risking food contamination and foodborne illness.
Deficiencies (2)
Failed to store all drugs and biologicals in locked compartments for two of four medication carts and nurses' station counter.
Failed to ensure food temperatures were checked on the steam table before serving residents.
Report Facts
Medication quantities: 30
Medication quantities: 30
Medication quantities: 30
Medication quantities: 14
Medication quantities: 30
Medication quantities: 30
Medication quantities: 30
Medication quantities: 60
Medication quantities: 60
Medication quantities: 60
Medication quantities: 28
Medication quantities: 30
Medication quantities: 90
Medication quantities: 120
Medication quantities: 60
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Oct 25, 2024
Visit Reason
The inspection was conducted due to allegations of verbal and mental abuse of residents by staff members, specifically involving Resident #34 and Resident #3.
Complaint Details
The complaint involved allegations of verbal and mental abuse of Resident #34 by the Weekend Activities Assistant and Resident #3 by CNA U. The abuse was substantiated, and the facility confirmed abuse had occurred. Immediate Jeopardy began on 07/08/24 and ended on 07/14/24 after the facility corrected the noncompliance.
Findings
The facility failed to protect residents from abuse, including verbal and mental abuse by staff, and failed to prevent retaliation against Resident #34 after reporting abuse. The facility also failed to immediately report alleged abuse to the Administrator. The abuse was confirmed and the responsible staff were terminated.
Deficiencies (4)
Facility failed to ensure Resident #34 was free from verbal and mental abuse by the Weekend Activities Assistant on 07/14/24.
Facility failed to ensure Resident #3 was free from verbal and mental abuse by CNA U on 07/08/24.
Facility failed to develop and implement written policies and procedures to prevent abuse and neglect of residents.
Facility failed to timely report suspected abuse and notify the Administrator immediately or within 2 hours.
Report Facts
Residents reviewed for abuse: 6
Residents affected: 2
Date of abuse incident for Resident #34: Jul 14, 2024
Date of abuse incident for Resident #3: Jul 8, 2024
Termination date of Weekend Activities Assistant: Jul 30, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Weekend Activities Assistant | Named in multiple abuse allegations and termination for gross misconduct. | |
| CNA U | Named in verbal and mental abuse allegation against Resident #3. | |
| Housekeeping Supervisor | Witnessed and reported abuse allegations involving Resident #34 and Weekend Activities Assistant. | |
| MA D | Witnessed and reported abuse allegations involving Resident #34 and Weekend Activities Assistant. | |
| WCN (Wound Care Nurse) | Witnessed abuse and reported to Administrator. | |
| Social Worker | Provided emotional support to Resident #34 and reported abuse concerns. | |
| Former Administrator | Abuse Coordinator during incident, involved in investigation and termination decisions. | |
| Psychiatric Nurse Practitioner | Provided psychiatric care and follow-up for Resident #34. |
Inspection Report
Complaint Investigation
Deficiencies: 10
Date: Oct 23, 2024
Visit Reason
The inspection was conducted due to allegations of abuse involving residents #34 and #3, including verbal and mental abuse by staff members.
Complaint Details
The complaint involved allegations of verbal and mental abuse by staff members towards residents #34 and #3. The facility investigation confirmed abuse had occurred and identified immediate jeopardy from 07/08/24 to 07/14/24. The facility corrected the noncompliance before the investigation began.
Findings
The facility failed to protect residents #34 and #3 from verbal and mental abuse by staff, failed to develop and implement policies to prevent abuse and neglect, failed to timely report abuse allegations, failed to provide adequate nail care for resident #74, failed to change and document nasal cannula care for resident #8, failed to secure medication carts, failed to provide adequate milk supply, and failed to provide pureed food items as ordered.
Deficiencies (10)
Failed to protect residents #34 and #3 from verbal and mental abuse by staff members.
Failed to develop and implement written policies and procedures that prohibit and prevent abuse and neglect of residents.
Failed to timely report alleged abuse to the facility Administrator within 2 hours.
Failed to ensure residents unable to carry out activities of daily living received necessary nail care.
Failed to ensure respiratory care was provided consistent with professional standards for resident #8; nasal cannula was not changed as ordered.
Failed to ensure drugs and biologicals were stored in locked compartments; medication cart for 100 Hall was left unlocked.
Failed to ensure adequate supply of milk for residents; residents reported not receiving milk with meals.
Failed to ensure menu was followed for pureed diet; resident #9 did not receive pureed bread and pureed angel food cake as ordered.
Failed to provide food prepared in a form designed to meet individual needs; pureed carrots contained chunks of carrot slices.
Failed to ensure medical records were accurately documented; LVN Y documented nasal cannula was changed on 10/20/24 when it was not.
Report Facts
Residents reviewed for abuse: 6
Residents on pureed diet: 5
Milk servings observed: 12
Nail care in-service frequency: 2
Food delivery frequency: 2
Food storage supply: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN Y | Licensed Vocational Nurse | Named in failure to change and document nasal cannula care for Resident #8. |
| LVN C | Licensed Vocational Nurse | Named in failure to secure medication cart for 100 Hall. |
| MA D | Medication Aide | Witnessed abuse and medication cart left unlocked. |
| CNA V | Certified Nursing Assistant | Witnessed abuse and failed to report abuse allegation immediately. |
| Weekend Activities Assistant | Activity Director | Named in multiple abuse allegations and termination for gross misconduct. |
| Former Administrator | Facility Administrator | Named as Abuse Coordinator and involved in abuse investigation. |
| WCN | Wound Care Nurse | Witnessed abuse and reported to Administrator. |
| MA D | Medication Aide | Witnessed abuse and reported to Administrator. |
| Social Worker | Social Worker | Provided information on resident emotional status and abuse investigation. |
| Dietary Manager | Dietary Manager | Named in milk supply and pureed food preparation failures. |
| Dietary District Manager | Dietary District Manager | Named in pureed food preparation failures. |
| LVN X | Licensed Vocational Nurse | Named in nasal cannula care failure. |
| ADON Z | Assistant Director of Nursing | Named in nasal cannula care failure and documentation issues. |
| Interim DON | Interim Director of Nursing | Named in nasal cannula care documentation failure. |
Inspection Report
Deficiencies: 0
Date: Dec 6, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Stonegate Nursing and Rehabilitation, summarizing the results of a survey completed on December 6, 2023.
Findings
No health deficiencies were found during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Aug 31, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to provide appropriate care for residents receiving enteral nutrition and respiratory care, and to ensure proper medication storage and accurate clinical documentation.
Complaint Details
The complaint investigation focused on concerns that the facility failed to provide appropriate care for residents receiving enteral nutrition and oxygen therapy, failed to securely store medications, and failed to maintain accurate clinical documentation. The investigation substantiated these concerns for Residents #65, #37, #30, and #73.
Findings
The facility failed to ensure appropriate labeling and administration of enteral feedings for two residents, failed to follow physician orders for oxygen therapy for one resident, failed to securely store medications for two residents, and failed to maintain accurate clinical records for one resident. These deficiencies posed risks of health complications, respiratory issues, medication errors, and inaccurate medical records.
Deficiencies (5)
Failure to appropriately label formula bag for Resident #65.
Failure to follow Resident #37's physician orders for enteral feeding.
Failure to follow physician orders for Resident #37's oxygen therapy.
Failure to ensure all drugs and biologicals were stored securely for Resident #30 and Resident #73.
Failure to maintain clinical records accurately for Resident #37, including incorrect documentation of feeding and oxygen therapy.
Report Facts
Residents reviewed for enteral nutrition: 6
Residents reviewed for respiratory care: 7
Residents observed for medication storage: 18
Residents records reviewed for treatment documentation: 18
Feeding rate for Resident #65: 70
Feeding rate for Resident #37: 65
Oxygen flow rate for Resident #37: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Nurse for Resident #65, involved in feeding bag labeling deficiency. |
| LVN B | Licensed Vocational Nurse | Nurse for Resident #37, involved in documentation and feeding order deficiencies. |
| LVN C | Licensed Vocational Nurse | Nurse for Resident #37, involved in oxygen therapy documentation deficiency. |
| LVN D | Licensed Vocational Nurse | Charge nurse involved in medication storage deficiencies. |
| ADON | Assistant Director of Nursing | Involved in multiple interviews and oversight related to feeding, oxygen therapy, and documentation. |
| DON | Director of Nursing | Provided expectations and oversight regarding physician orders, documentation, and medication storage. |
Inspection Report
Routine
Deficiencies: 1
Date: Aug 17, 2023
Visit Reason
The inspection was conducted to assess the facility's infection prevention and control program, specifically focusing on compliance with disinfecting reusable medical equipment between resident uses.
Findings
The facility failed to maintain an effective infection prevention and control program by not disinfecting the blood pressure cuff between uses on four of five residents reviewed, posing a risk of cross contamination and potential infections. Staff interviews and record reviews confirmed the failure and the facility's policy requirements.
Deficiencies (1)
Failure to disinfect the blood pressure cuff between blood pressure checks for Residents #1, #2, #3, and #4.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MA A | Observed failing to disinfect blood pressure cuff between resident uses and interviewed about infection control knowledge. | |
| ADON | Interviewed regarding staff training and infection control expectations. | |
| DON | Interviewed regarding infection control expectations and staff training. |
Inspection Report
Routine
Deficiencies: 1
Date: Aug 17, 2023
Visit Reason
The inspection was conducted to assess the facility's infection prevention and control program, specifically to evaluate compliance with disinfecting reusable medical equipment between resident uses.
Findings
The facility failed to maintain an effective infection prevention and control program by not disinfecting the blood pressure cuff between residents, which could lead to cross contamination and potential infections. Staff interviews confirmed awareness of the requirement, but the failure occurred during observed care.
Deficiencies (1)
Failure to disinfect the blood pressure cuff between blood pressure checks for Residents #1, #2, #3, and #4.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MA A | Observed failing to disinfect blood pressure cuff between residents and interviewed regarding infection control awareness. | |
| ADON | Interviewed about staff training and infection control responsibilities. | |
| DON | Interviewed about expectations for disinfecting reusable medical equipment and staff training. |
Inspection Report
Routine
Deficiencies: 2
Date: May 26, 2023
Visit Reason
The inspection was conducted to assess compliance with requirements related to posting daily nurse staffing information as required by regulations.
Findings
The facility failed to post the daily nurse staffing information on 05/26/23, which could place residents, families, and visitors at risk of not having access to staffing and census information. The staffing coordinator had not posted the information since being hired and only provided it in a staffing book inaccessible to residents or visitors.
Deficiencies (2)
Failure to post daily nurse staffing information as required.
Staffing information for 05/25/23 and 05/26/23 did not reveal staffing for each shift.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ADM | Assistant Director of Nursing | Interviewed regarding awareness and responsibility for posting nurse staffing information. |
| DON | Director of Nursing | Interviewed regarding staffing coordinator's responsibility and accessibility of staffing information. |
| Staffing Coordinator | Interviewed regarding failure to post nurse staffing information and staffing book accessibility. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Feb 28, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Stonegate Nursing and Rehabilitation, summarizing the findings from the annual survey completed on 02/28/2023.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 3, 2023
Visit Reason
The inspection was conducted due to concerns regarding the facility's failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for Resident #1, as part of a complaint investigation.
Complaint Details
The investigation was complaint-related, focusing on wound care deficiencies for Resident #1. The complaint was substantiated based on findings of missed wound care treatments and lack of proper wound physician consultation.
Findings
The facility failed to ensure that Resident #1 received necessary wound care treatment for a stage II coccygeal pressure ulcer, with multiple missed treatments documented between 09/28/22 and 10/16/22. The wound care orders were not properly transcribed or followed, and the wound physician was not consulted on admission. Interviews with staff revealed gaps in communication and responsibility for wound care assessments and orders.
Deficiencies (1)
Failure to provide wound care treatment BID or PRN on multiple dates for Resident #1's pressure ulcer.
Report Facts
Missed wound care treatment dates: 9
Stage of pressure ulcer: 2
Stage of pressure ulcer: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ADON A | Assistant Director of Nursing | Oversaw long-term care unit and provided information about wound care responsibilities and resident transfers. |
| ADON B | Assistant Director of Nursing | Oversaw skilled/rehab unit and described wound care assessment and communication responsibilities. |
| DON | Director of Nursing | Provided information on skin assessments, wound care procedures, and facility policy. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 3, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction report for Stonegate Nursing and Rehabilitation following a survey completed on 02/03/2023.
Findings
No health deficiencies were found during the survey.
Inspection Report
Routine
Deficiencies: 6
Date: Jul 14, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, bed rail use, medication storage, and infection control.
Findings
The facility failed to complete timely quarterly Minimum Data Set (MDS) assessments, failed to transmit MDS data timely, and did not develop comprehensive care plans with measurable objectives for some residents. The facility also failed to obtain informed consent for bed rail use for several residents, left medications unsecured in a resident's room, and did not consistently follow infection prevention and control protocols including hand hygiene, glove use, and equipment disinfection.
Deficiencies (6)
Failed to complete a quarterly Minimum Data Set assessment for Resident #57 as required.
Failed to electronically transmit encoded, accurate, and complete MDS data to the CMS System timely for Residents #2 and #11.
Failed to develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes for Resident #63's dialysis.
Failed to review risks and benefits of bed rails and obtain informed consent prior to installation for seven residents (#25, #30, #43, #46, #53, #167, and #169).
Failed to ensure all drugs and biologicals were stored securely; a bottle of Nystatin was left unsupervised in Resident #44's room.
Failed to maintain an infection prevention and control program including disinfecting blood pressure cuffs between residents, changing gloves during wound care, performing hand hygiene during blood sugar checks, and proper sharps disposal.
Report Facts
Residents reviewed for comprehensive assessments: 14
Residents affected by bed rail consent deficiency: 7
Residents reviewed for infection control: 14
Residents affected by infection control deficiencies: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Named in multiple findings related to failure to complete and transmit MDS assessments and care plan deficiencies. | |
| Interim DON | Director of Nursing | Interviewed regarding expectations for MDS completion, care plans, bed rail monitoring, medication storage, and infection control. |
| ADON | Assistant Director of Nursing | Interviewed regarding responsibilities for MDS completion and care plan accuracy. |
| LVN A | Licensed Vocational Nurse | Observed and interviewed regarding medication storage and handling for Resident #44. |
| MA C | Medical Assistant | Observed and interviewed regarding failure to disinfect blood pressure cuff between residents. |
| LVN D | Licensed Vocational Nurse | Observed and interviewed regarding failure to change gloves during wound care for Resident #14. |
| LVN E | Licensed Vocational Nurse | Observed and interviewed regarding failure to perform hand hygiene and improper sharps disposal during blood sugar check for Resident #36. |
| Traveling DON | Director of Nursing | Interviewed regarding bed rail audits and consent practices. |
| CNA B | Certified Nursing Assistant | Interviewed regarding resident mobility and care needs. |
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