Nightingale At Stonegate

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. A strap on the chair was observed to have black, orange, brown, grey and white residues on the clasp and along the length of the strap. The larger shower chair also had black spotted residue on the back of the chair and legs and orange, brown, grey and white residue on the seat back and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. Resident is to be up for all meals. 2. Resident #50 had diagnoses of Dementia and muscle weakness. According to a Quarterly MDS with an ARD of 02/27/2024 Resident #50 scored 13 (13-15 indicates cognitively intact) on a BIMS. The care plan documented that Resident #50 required assistance with eating. 3. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. An Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/12/2024 documented Resident #6 had a Brief Interview for Mental Status (BIMS) score of 6 (00-07 indicates severe cognitive impairment) and an active diagnosis of non-Alzheimer ' s dementia. b. A Care Plan revised on 03/14/2024 had no documented interventions regarding Dementia Care. c. On 04/12/2024 at 02:31 PM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. On 04/09/2024 at 09:59 AM, an opened box of biscuits was on a shelf in the freezer. The box was not covered, and was not completely sealed, exposing it to cross contamination. There was no date on the box to indicate when it was opened. 2. On 04/09/2024 at 10:09 AM, the following observations were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident and or resident representative and the Office of the State Long-Term Care Ombudsman were provided written documentation regarding a transfer to the hospital for 1 (Resident #21) of 1 sampled resident reviewed for transfer / discharge to the hospital. The findings are: Resident #21 was admitted to the facility on [DATE] as documented on a Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/21/2024. Resident #21 had a Brief Interview for Mental Status (BIMS) score of 6 (00-07 indicates severely impaired). a. A Progress Note dated 01/13/2024 at 8:16 AM documented, .resident noted to be vomiting dark brown emesis with foul odor noted .received orders to send resident to [local hospital] ER [Emergency Room] for further eval/tx [evaluation / treatment]. resident transferred via [by way of] [ambulance service] . b. On 04/11/2024 at 06:00 AM, Resident #21's electronic health record was reviewed and there was no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident and/or resident representative was provided a copy of a bed hold policy after a transfer to the hospital for 1 (Resident #21) of 1 sampled resident reviewed for bed-hold policy notification. The findings are: 1. Resident #21 was admitted to the facility on [DATE] as documented on a Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/21/2024. Resident #21 had a Brief Interview for Mental Status (BIMS) score of 6 (00-07 indicates severe cognitive impairment). a. A Progress Note dated 01/13/2024 at 08:16 AM documented, .resident noted to be vomiting dark brown emesis with foul odor noted .received orders to send resident to [local hospital] ER [Emergency Room] for further eval/tx [evaluation / treatment]. resident transferred via [by way of] [ambulance service] . b. On 04/11/2024 at 06:00 AM, Resident #21's electronic health record was reviewed and there was no documentation regarding a bed hold notification…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure nail care was consistently provided to promote good grooming and personal hygiene for 1 (Resident #54) of 1 sampled resident who required staff assistance with nail care. The findings are: 1. Resident #54 had diagnoses of reduced mobility and muscle wasting, as documented in an Order Summary Report. a. An admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/26/2024 documented Resident #54 had a Brief Interview for Mental Status (BIMS) score of 11 (08-12 indicates moderately cognitive impaired) and had an impairment in range of motion on one side in an upper extremity which included the shoulder, elbow, wrist, and hand. b. A Care Plan dated 03/06/2024 documented Resident #54 had a deficiency in performing Activities of Daily Living (ADL) due to a Cerebrovascular Accident (CVA), also known as a Stroke, required extensive care with personal hygiene and nail length was to be checked, trimmed, and cleaned on bath day and as necessary. c. On 04/09/2024 at 01:50 PM, Resident #54 said…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure that staff used proper hand hygiene when assisting residents during meal service to prevent spread of bacteria, viruses, and/or infections. This failed practice had the potential to affect 2 (Residents #7, #50) sampled residents residing in the facility requiring assistance with meal service. The findings are: On 04/09/2024 at 12:11 PM, the Surveyor observed Certified Nursing Assistant (CNA) #1 positioning Resident #7 to an upright position in a Geri-chair (a type of chair that is useful for those with mobility issues and can also be used for bedridden patients who have difficulty sitting upright in a conventional wheelchair). CAN #1 did not sanitize/wash hands after contact with Resident #7. CNA #1 picked up silverware from the table and initiated meal assistance for Resident #50. CNA #1 placed a napkin over Resident #7 shirt, tucking the napkin in the Resident's shirt (encountering Resident's skin) and did not wash/sanitize hands. CNA #1 took silverware from Resident #50's hand, who was attempting to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the admission Evaluation accurately assessed 1 (Resident #100) of 1 sampled resident whose admission Evaluation was reviewed for the use of psychotropic medications and smoking. The findings are: Resident #100 was admitted on [DATE] and had diagnoses of Atherosclerosis of Coronary Artery, Type 2 Diabetes Mellitus and Primary Hypertension. The Medicare 5 Day Minimum Data Set (MDS). was still in progress. As documented on a list provided by the Director of Nursing (DON) on 04/20/23 at 11:23 AM, Resident #100 smoked. a. The Physician orders dated 04/06/23 documented, .risperiDONE Oral Tablet 1 MG (Risperidone) Give 1 tablet by mouth one time a day for Delirium for 30 Days . b. The admission Evaluation dated 04/06/23 documented, .2. Medications .D. Abnormal Involuntary Movement Scale (AIMS) 1. Does the resident/elder receive ANY psychotropic medications such as antipsychotics, antidepressants, antianxiety, sedatives or hypnotics? b. No…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure 1 (Resident #12) of 2 (Residents #12 and #100) sampled residents who smoked as documented on a list provided by the Director of Nursing (DON) on 04/20/23 at 11:23 AM, was supervised while smoking to prevent potential accidents. The findings are: 1. Resident #12 had diagnoses of Hemiplegia and Hemiparesis following unspecified Cerebrovascular Disease Affecting Unspecified Side and Muscle Weakness and Unspecified Lack of Coordination. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/07/23 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and was independent with set up help only with locomotion on the unit. a. A Smoking - Safety Screen dated 12/05/22, provided by the Director of Nursing (DON) on 04/19/23 at 11:11 AM documented, .E. SAFETY 6. Can resident light own cigarette? No . 7. RESIDENT NEED FOR ADAPTIVE EQUIPMENT 7a. Smoking apron . 7c. Supervision . 8. Does resident need facility to store lighter…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, and interview, the facility failed to ensure 300 Hall medication cart was locked when out of the nurse's line of vision to keep medications and biologicals securely stored and to prevent potential access by residents or visitors. This failed practice had the potential to affect 14 self-mobile residents who resided on the 300 Hall as documented on a list provided by the Director of Nursing (DON) on 04/20/23 at 11:20 AM. The findings are: 1. On 04/20/23 at 8:17 AM, Licensed Practical Nurse (LPN) #1 was on the 300 Hall preparing mediations outside of a resident's room. LPN #1 entered the resident's room leaving the medication cart facing the hall unlocked. No other facility staff was in sight. The Surveyor was standing beside the cart and observed 3 residents in manual wheelchairs come within reach of the medication cart. The medication cart was unlocked and not supervised, and accessible to residents on the 300 Hall for 7 minutes. 2. On 04/20/23 at 8:24 AM, when LPN #1 came out of the resident's room, the Surveyor asked, Should your medication cart be locked when…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.