Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in
locked compartments for two (Medication Cart #1 and Medication Cart #2) of four medication carts and
nurses' station counter (Hall 200- East Station) reviewed for medication storage.
1. The facility failed to lock Medication Cart #1 and Medication Cart #2 on 01/02/25, leaving all medications
on the cart accessible on Hall 100 (West Station).
2. The facility failed to secure medications on the nurses' station counter on Hall 200 (East Station) on
01/03/25 at 5:30 AM.
These failures could place residents at risk for drug diversions.
Findings included:
Observation on 01/02/25 at 3:30 PM revealed Medication Cart #1 was unlocked, and the top and second
drawers were open completely facing a resident room. Observation of Medication Cart #2 revealed the
medication cart was unlocked, and the drawers were facing the open entry way.
Observation on 01/03/25 at 5:30 AM of the 200 Hall (East Station) revealed medications were left out
unattended, in reach of residents, and visible at the nurses' station counter:
*Theophylline ER 300 mg tab, quantity: 30
*Potassium CL Micro ER 10 meq tab, quantity: 30
*Aripiprazole 2 mg tab, quantity: 30
*Jardiance 10 mg tab, quantity: 14
*Escitalopram 10 mg tab, quantity: 30
*Atorvastatin 10 mg tab, quantity: 30
*Ezetimibe 10 mg tab, quantity: 30
*Levetiracetam 500 mg tab, quantity: 60
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 4
Event ID:
675759
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675759
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/03/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Stonegate Nursing and Rehabilitation
4201 Stonegate Blvd
Fort Worth, TX 76109
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
*Ranolazine ER 500 mg tab, quantity: 60
Level of Harm - Minimal harm
or potential for actual harm
*Tamsulosin 0.4 mg cap, quantity: 60
*Eliquis 5 mg tab, quantity: 28
Residents Affected - Some
*Furosemide 20 mg tab, quantity: 30
*Isosorbide Dinitrate 20 mg tab, quantity: 90
*Metformin 1000 mg tab, quantity: 120
*Metoprolol Tartrate 75 mg tab, quantity: 60
Interview on 01/02/25 at 3:02 PM with MA H revealed medication carts were supposed to be locked when
not in use.
Interview on 01/03/25 at 5:35 AM with LVN G revealed the medications came in last night, and she was in
the process of sorting out the medications and was putting the medications in the medication cart.
Interview on 01/03/25 at 5:40 AM with LVN I, a PRN nurse, revealed medications were supposed to be put
up in the medication cart or medication room when delivered. LVN I stated the medications were sorted out
by name and put in the medication cart. LVN I stated residents could take the medications when left out or
medication cart unlocked.
Interview on 01/03/25 at 6:16 AM with LVN J revealed medication carts not being used were supposed to
be locked at all times when not in use. LVN J stated residents could take medications that were left out.
Interview on 01/03/25 at 6:35 AM with LVN K revealed medications could not be left out because residents
could take the medications. LVN K stated medication carts could not be left unlocked when they were not
being used.
Interview on 01/03/25 at 11:50 AM with ADON A and ADON L revealed medications were supposed to be
put up as soon as they came in. Medication carts were supposed to be locked when not being used.
Interview on 01/03/25 at 1:10 PM with the DON revealed when medications were delivered the nurse
should sign for the medications and put the medications away in the medication carts. DON C stated
residents could take medications.
Record review of the pharmacy delivery manifest dated 01/02/25 reflected the medications were delivered
at 10:26 PM on 01/02/25.
Record review of the facility's Security of Medication Cart, revised April 2007 reflected: The nurse must
secure the medication cart during the medication pass to prevent unauthorized entry .3. The cart must be
locked before nurse enters the resident's room .4. Medication carts must be securely locked at all times
when out of the nurse's view.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675759
If continuation sheet
Page 2 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675759
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/03/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Stonegate Nursing and Rehabilitation
4201 Stonegate Blvd
Fort Worth, TX 76109
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
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 1 of 1 kitchen, in that:
Residents Affected - Many
The facility failed to ensure food temperatures were checked on 01/03/25 while on the steam table before
serving residents between 7:00 AM to 8:30 AM.
These failures could place residents, who receive food from the kitchen, at risk for food contamination and
foodborne illness.
Findings included:
Observation on 01/03/25 in the kitchen revealed the following:
7:00 AM - a pan of oatmeal, scrambled eggs, pureed, mechanical soft meat were on the steam table
uncovered;
7:23 AM - [NAME] A put omelets on the steam table;
7:25 AM - toast was taken out of the oven and place in a different pan and then put on the steam table;
7:40 AM - bacon was put on top of the steam table. [NAME] A plated food without checking the
temperatures;
7:56 AM - trays for 100 Hall were completed and sent out;
7:57 AM - [NAME] A added bread to the steam table;
8:16 AM - trays for 200 Hall were completed and sent out; and
8:30 AM - trays for 300 Hall were completed and sent out.
Interview on 01/03/25 at 8:35 AM with [NAME] A revealed she was running behind and did not check
temperatures for the breakfast food before serving. [NAME] A stated by not checking the temperatures the
residents could get food that were too cold or too hot.
Interview on 01/03/25 at 8:45 AM with the Dietary Manager revealed the [NAME] was supposed to check
temperatures on the steam table before food was served to the residents. She stated food could be
contaminated, and the residents could be served cold food. She stated the temperatures were checked on
the days that were blank on the temperature log for December and January. The Dietary Manager stated
[NAME] A wrote the temperature logs and a different place. She stated the temperatures should be written
down in the log book as the tempertures are checked. She stated she checked the temperature book, and
she updated the temperature log to reflect those temperatures.
Interview attempted to with the facility's Dietitian on 01/03/25 at 9:00 AM via telephone; however,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675759
If continuation sheet
Page 3 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675759
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/03/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Stonegate Nursing and Rehabilitation
4201 Stonegate Blvd
Fort Worth, TX 76109
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
the Dietitian did not call back prior to exit.
Level of Harm - Minimal harm
or potential for actual harm
Interview attempted with [NAME] N on 01/03/25 at 9:00 AM via telephone; however, [NAME] N did not call
back prior to exit.
Residents Affected - Many
Interview on 01/03/25 at 1:30 PM with the Administrator revealed dietary staff should be bringing trays out
like 10 at a time to make sure the resident's food was hot, not setting up all the trays, and then serving the
residents.
Record review of the facility's Food Preparation and Service policy reflected: Cooking and holding
temperatures and times: The danger zone for food temperatures is between 41 degrees and 135 degrees
Fahrenheit. This temperature range promotes the rapid growth of pathogenic microorganisms that cause
foodborne illness. Potentially hazardous foods include meats, poultry, seafood, cut melon, eggs, milk,
yogurt, and cottage cheese. The following internal cooking temperatures/times for specific foods must be
reached to kill or sufficiently inactivate pathogenic microorganisms: 5.Poultry and stuffed foods - 165 F.
Ground meat, ground fish and eggs held for service - at least 115 F Fish and other meats - 145 F for 15
seconds .Food Distribution and service .3. The temperature of foods held in steam tables will be monitored
by food service staff .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675759
If continuation sheet
Page 4 of 4
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the January 3, 2025 survey of STONEGATE NURSING AND REHABILITATION?
This was a inspection survey of STONEGATE NURSING AND REHABILITATION on January 3, 2025. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at STONEGATE NURSING AND REHABILITATION on January 3, 2025?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional princip..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.