Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Life Care Center Of Stonegate during CMS and state inspections, most recent first.
The facility did not ensure an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors.
A plan to meet a resident's most immediate needs was not created or implemented within 48 hours of admission, as required. Surveyors found no documentation or evidence that this process occurred for a newly admitted resident.
A resident in a long-term care facility received an incorrect dosage of carvedilol due to a transcription error by an LPN, which was not caught by a second LPN. The resident was given four times the prescribed dose, leading to significant hypotension and hospitalization. The facility failed to follow professional standards in medication administration, resulting in the resident's adverse health event.
The facility failed to provide adequate pressure ulcer care and prevention for eight residents, leading to deficiencies in treatment and documentation. A resident developed a facility-acquired unstageable coccyx wound due to delayed skin assessments and interventions. Another resident, at risk for pressure wounds, did not have effective personalized preventative measures, and there were inconsistencies in documenting and treating pressure wounds as per physician orders. Additional deficiencies were noted in the care of residents with existing pressure wounds, including lack of timely assessments and failure to consistently check pressure-relieving devices.
The facility failed to honor the bathing preferences of four residents, leading to a deficiency in promoting resident self-determination. Despite residents expressing their preferences, the facility did not document or provide showers as scheduled. Care plans lacked specific details on bathing preferences, and staff interviews revealed inconsistencies in documentation practices.
The facility failed to provide appropriate skin care for two residents and did not ensure timely notification of a delay in starting antibiotics for another resident. One resident did not receive prescribed barrier cream as ordered, while another did not receive triad cream as frequently as required. Additionally, a resident with a hip infection missed four doses of Ampicillin, and there was no documentation of provider notification. Staff interviews revealed gaps in communication and documentation practices.
The facility failed to maintain an effective infection control program, with observed deficiencies in hand hygiene during wound care, improper handling of a suction canister, and inadequate disinfection of medical equipment. Staff interviews revealed a lack of awareness and adherence to protocols, contributing to these lapses.
The facility failed to maintain an effective training program for agency staff, as evidenced by incomplete orientation skills checklists and missing orientation packet receipts. Interviews revealed that some staff did not receive formal orientation and had to rely on peers for guidance. The Director of Nursing was unaware of the orientation process, and the staffing coordinator had only recently assumed responsibility for staff orientation.
A facility failed to consistently complete pre- and post-dialysis communication forms for a resident requiring dialysis, as per professional standards. The resident, over 65 with end-stage renal disease, had multiple instances of incomplete documentation, missing vital signs, weights, and signatures. Interviews with staff confirmed these lapses, highlighting the importance of proper documentation for monitoring the resident's condition and ensuring effective communication with the dialysis center.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. This deficiency was identified based on observations and findings by surveyors, indicating that the environment posed risks for accidents and that supervision measures in place were insufficient to prevent such incidents. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Develop and Implement Immediate Needs Plan Within 48 Hours of Admission
Penalty
Summary
A plan to address a resident's most immediate needs within 48 hours of admission was not created or implemented. This deficiency was identified based on the absence of documentation or evidence that such a plan was developed and put into place for newly admitted residents. The lack of timely planning for immediate needs upon admission was observed during the survey.
Medication Error Leads to Hospitalization
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, resulting in the resident receiving an incorrect dosage of carvedilol. Upon admission, the resident's physician ordered carvedilol 6.25 mg twice daily for hypertension and heart failure. However, an LPN incorrectly transcribed the order as 25 mg twice daily, which is four times the prescribed dose. Another LPN confirmed the incorrect order without catching the discrepancy. The resident was administered the incorrect dose on two occasions, leading to significant hypotension. The resident's blood pressure dropped to dangerously low levels, and he was transferred to the hospital's intensive care unit for treatment of a medication overdose. The resident required intravenous medications to stabilize his blood pressure and circulation. The error was identified after the resident experienced adverse effects, and it was confirmed that the facility had not followed professional standards of nursing practice in transcribing and confirming medication orders. The incident highlighted a failure in the facility's medication administration process, which resulted in the resident's hospitalization.
Removal Plan
- Resident #287 was assessed following the administration of the two larger doses of carvedilol. The physician was promptly notified and new orders for the correct dose were obtained. The resident was notified of the error and sent to the hospital for further evaluation. The resident's primary care physician at the facility reviewed the medical record and supplied the facility with his findings.
- Education was done with the two nurses who transcribed and verified the medication order upon admission.
- A root cause analysis was completed with the involved nurses, and corrective action was implemented based on the findings.
- The facility reviewed hospital discharge medication orders and facility admission medication orders. Out of 41 admissions that were reviewed, there was one other error noted. That error had no adverse outcomes. The physician was notified and corrective action was implemented.
- Admission orders education was conducted and included the following: All admission orders will have a second check completed by a nurse, The second check should consist of verifying the correct admission orders were entered by the first nurse, Orders should not be confirmed unless they meet the 10 rights of medication administration: right patient, medication, time, dose, route, right education/advice, right to refuse, right assessment, right evaluation/response and right documentation.
- 52 staff completed education on admission orders.
- 112 staff completed education regarding double checking blood pressures if abnormal results were obtained the first time.
- Review of medications will be done by the pharmacist upon admission and as needed.
- Admission orders from the hospital are reviewed and entered by a nurse. A second nurse reviews the orders, comparing them to the transfer orders from the hospital.
- If a medication error is identified, the process for medication variance will be followed, including prompt action to maintain safety for the resident, communicating with the physician, and implementing any provided orders. Additional education will be done with the nurses involved.
- If significant abnormal vital signs are obtained, a second check will be completed using a manual cuff (for blood pressures). The DON will identify significantly abnormal vital signs and determine if re-checks have been completed.
- The DON or designee will report audit findings and medication regimen review findings to the Facility quality assurance process improvement (QAPI) committee. The committee will review the findings and determine if the facility has achieved substantial compliance. The frequency of ongoing monitoring will be determined by the facility QAPI committee.
- Education for nurses will be done upon hire and as needed regarding the facility process for transcribing and checking medication orders upon admission, rechecking abnormal vital signs, and the policy/procedure related to medication administration and errors.
Inadequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for eight residents, leading to deficiencies in treatment and documentation. Resident #239 developed a facility-acquired unstageable coccyx wound due to delayed skin assessments and interventions. The resident's care plan was not initiated promptly, and there were lapses in documenting wound care. Similarly, Resident #59, who was at risk for pressure wounds, did not have effective personalized preventative measures, and there were inconsistencies in documenting and treating pressure wounds as per physician orders. Resident #232 was admitted with an unstageable coccyx pressure wound, but timely and effective preventative measures were not in place, and skin assessments were inaccurately documented. Resident #231 had a right heel deep tissue injury that was not accurately assessed upon admission, and personalized skin prevention interventions were lacking. Resident #183, with a stage 3 pressure wound, did not receive consistent pressure ulcer treatments as ordered by the physician. Additional deficiencies were noted for Resident #23, who had a stage 3 coccyx wound, as the air mattress was not consistently checked. Resident #36, with a stage 2 pressure wound, did not have a skin assessment performed as required. Lastly, Resident #21, admitted with a stage 3 pressure wound, did not receive a timely skin assessment. These failures highlight the facility's inability to adhere to professional standards of practice in preventing and managing pressure injuries.
Failure to Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to honor the bathing preferences of four residents, leading to a deficiency in promoting and facilitating resident self-determination. Resident #71, who was cognitively intact, expressed dissatisfaction with not receiving showers as per her preference of twice a week. Despite her refusal on one occasion due to scheduling conflicts, the facility did not reschedule her shower, resulting in her receiving only four showers out of nine opportunities. The care plan and Kardex for Resident #71 did not specify her bathing preferences, contributing to the oversight. Resident #130, who had severe cognitive impairment, was not documented as having received or been offered a shower during his stay, except on the day of discharge. His care plan also lacked details on his bathing preferences, indicating a systemic issue in documenting and honoring resident choices. Similarly, Resident #183, who was cognitively intact but physically dependent, reported not being offered a shower since admission. His care plan and Kardex failed to include his bathing schedule or preferences, and there was no documentation of any showers being offered or provided. Resident #186, with severe cognitive impairments, also had a care plan that did not specify her bathing preferences or assistance level required. Although her task report indicated a bathing schedule, there was no documentation of showers being provided or refused. Staff interviews revealed inconsistencies in documentation practices, with CNAs and LPNs unable to verify recorded showers. The facility's DON and DDCS acknowledged previous issues with shower documentation and the need for staff retraining, highlighting a broader problem with maintaining accurate records of resident care.
Deficiencies in Skin Care and Antibiotic Administration
Penalty
Summary
The facility failed to provide appropriate skin care treatment for two residents, as per physician orders. Resident #181, who was bed-bound and required assistance for all activities of daily living, had a physician's order for barrier cream to be applied twice daily to prevent skin breakdown. However, the treatment administration record (TAR) showed that the cream was only applied once daily on several occasions. Similarly, Resident #177, who had significant wounds and was at high risk for hospital readmission, had a physician's order for triad cream to be applied three times daily. The TAR indicated that the cream was only applied twice daily, and there was no documentation of refusal of care on the days when treatment was missed. The facility also failed to ensure timely notification of a delay in starting antibiotics for Resident #240, who was admitted with an infection of a hip prosthesis. The resident's medication administration record (MAR) documented that four doses of Ampicillin were unavailable and missed, yet there was no evidence that the provider was notified of this delay. Additionally, during a change in the resident's condition, there was a lack of documentation of a comprehensive physical assessment and vital signs monitoring, which are critical in such situations. Interviews with staff revealed gaps in communication and documentation. Licensed Practical Nurse (LPN) #1 was unsure why documentation was missing, and the Director of Nursing (DON) acknowledged that refusals of care should have been documented. The DON and the Divisional Director of Clinical Services (DDCS) emphasized the importance of documenting treatment administration and refusals. In the case of Resident #240, Registered Nurse (RN) #1 and the DDCS confirmed that the provider should have been notified of the antibiotic delay, and a head-to-toe assessment should have been conducted during the resident's change in condition.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program across all three units, as evidenced by several observed deficiencies. During wound care for two residents, the infection preventionist (IP) and the director of nursing (DON) did not adhere to proper hand hygiene protocols. The IP failed to perform hand hygiene after removing gloves and before donning new ones, while the DON did not wear a gown when assisting with wound care, contrary to Enhanced Barrier Precautions (EBP) guidelines. These lapses were confirmed through staff interviews, where the DON admitted to being unaware of the need for a gown during such procedures. Additionally, a suction canister containing oral secretions was left undated and improperly stored at a resident's bedside for an extended period. This was observed over two consecutive days, with the canister remaining in the same unsanitary condition. Interviews with staff, including a licensed practical nurse (LPN) and the DON, revealed a lack of awareness regarding the proper disposal of used suction canisters, which are potential sources of infection. Further deficiencies were noted in the handling of medical equipment. A registered nurse (RN) failed to disinfect a glucometer and vital signs machines between uses on different residents, as required by facility policy and CDC guidelines. The RN admitted to not being familiar with the facility's cleaning protocols for glucometers and acknowledged forgetting to clean the vital signs machine. These oversights were corroborated by observations and interviews with the DON and divisional director of clinical services (DDCS), who confirmed the facility's expectations for equipment disinfection.
Deficiency in Staff Orientation and Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all staff, including contract agency staff, as required by the facility assessment and resident population needs. Specifically, the facility did not complete orientation skills checklists and did not ensure receipt of orientation packets for agency nursing staff. These packets were supposed to include essential information on general orientation, medication administration, electronic medical record access, laundry procedures, resident transfers, gait belt usage, and nursing documentation. The record review revealed multiple instances where agency staff, including registered nurses (RNs) and certified nurse aides (CNAs), either did not have a signed receipt of the orientation packet or did not have a completed orientation skills checklist. Interviews with staff further highlighted the deficiency. An RN who had been working at the facility for a year reported not receiving any formal orientation, orientation packet, or skills checklist, and had to rely on other staff members for guidance. The Director of Nursing (DON), who was new to the facility, was unaware of the orientation process for agency staff, while the staffing coordinator (SC) admitted to taking over the orientation role recently due to a staff resignation. The SC acknowledged that the orientation skills checklist was only introduced in May 2023, and there was no clear explanation for the lack of completed orientation documentation for agency staff who had been working at the facility for a year.
Failure to Complete Dialysis Communication Forms
Penalty
Summary
The facility failed to provide dialysis care consistent with professional standards for a resident requiring such services. The deficiency was identified through observations, record reviews, and interviews, revealing that the facility did not consistently complete the pre- and post-dialysis assessment sections on the dialysis communication forms for a resident. The facility's policy required ongoing assessment and communication with the dialysis center, including completing a pre- and post-dialysis communication form with vital signs and other relevant information. The resident involved was over 65 years old, diagnosed with end-stage renal disease, and dependent on renal dialysis. The resident was cognitively intact and required assistance with certain activities of daily living. The facility had a physician's order for the resident to receive dialysis three times a week. However, a review of the dialysis communication forms from late August to late September revealed multiple instances where the forms were not completed appropriately, missing vital signs, weights, and signatures in both pre- and post-dialysis sections. Interviews with facility staff, including an LPN and the DON, confirmed the lapses in documentation. The LPN acknowledged that vital signs should have been checked and recorded before the resident's dialysis appointments, and the DON emphasized the importance of completing the communication forms to monitor the resident's condition and facilitate communication with the dialysis center. The failure to document vital signs and other necessary information on the communication forms was attributed to various reasons, including the resident's occasional low blood pressure, which might have led to missed dialysis sessions.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 337 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Parker
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parker Post Acute | 1.6 mi | — | 19 | 0 |
| Center At Lincoln, Llc, The | 3.8 mi | — | 1 | 0 |
| Beth Israel At Shalom Park | 7.2 mi | — | 10 | 0 |
| Brookdale Greenwood Village | 7.8 mi | — | 5 | 0 |
| Silver Heights Skilled Nursing And Rehabilitation | 9 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.