STONECREST HEALTHCARE
For profit - Corporation
60 Beds
RELIANT CARE MANAGEMENT
Data: November 2025
Trust Grade
65/100
#208 of 479 in MO
Last Inspection: March 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Stonecrest Healthcare in Viburnum, Missouri, has a Trust Grade of C+, indicating it is slightly above average in quality but not exceptional. It ranks #208 out of 479 nursing facilities in the state, placing it in the top half, and #2 out of 2 in Iron County, meaning there is only one other local option. The facility shows an improving trend, reducing issues from six in 2024 to one in 2025. However, staffing is a concern with a low rating of 1 out of 5 stars, despite a turnover rate of 52% that is slightly better than the state average. While there were no fines reported, there were significant issues noted, including unsafe food storage practices that could risk foodborne illness and a pest control problem that allowed flies to infest the dining area. Additionally, the facility failed to provide necessary contact information for residents regarding rights and advocacy, which is a critical oversight. Overall, while there are strengths in RN coverage and a lack of fines, families should weigh these against the staffing challenges and reported concerns.
- Trust Score
- C+
- In Missouri
- #208/479
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 52% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Missouri facilities.
- Skilled Nurses ○ Average
- Each resident gets 40 minutes of Registered Nurse (RN) attention daily — about average for Missouri. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 20 deficiencies on record. Higher than average. Multiple issues found across inspections.
65/100
Top 43%
No red flags
6 → 1 violations
★★★☆☆
3.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2024: 6 issues
2025: 1 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
3-Star Overall Rating
Above Missouri average (2.5)
Meets federal standards, typical of most facilities
Staff Turnover: 52%
Near Missouri avg (46%)
Higher turnover may affect care consistency
Chain: RELIANT CARE MANAGEMENT
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 20 deficiencies on record
Jul 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0628
(Tag F0628)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide written information to the resident and/or the resident's r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide written information to the resident and/or the resident's representative for the ombudsman (resolves complaints for residents of long term care facilities) contact information, the contact information for the agency responsible for protective and advocacy of individuals with mental disorders, contact information for the protection and advocacy of individuals with development disabilities, and appeal information for two residents (Residents #20 and #45) out of two sampled residents. The facility's census was 54.Review of the facility’s policy titled, “Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave, dated 04/25/25, showed:
Purpose is to establish a policy and procedure regarding the transfer/discharge of residents. To ensure no inappropriate discharges are made and that no discharges are made in an unsafe manner;
Residents who are sent emergently to the hospital are considered transfers because the resident’s return is generally expected;
Notification of resident and resident representative with the reason for the transfer or discharge in writing should occur;
The notice should include: reason for transfer/discharge; effective date; location to which resident is going; resident’s right to appeal, name, address, email and number of the long-term care ombudsman office; for residents with development disabilities the mailing address, email, and the telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities; and for residents with mental disorders related to a disability the mailing address, email, and the telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder.
1. Review of Resident #20’s medical record showed:
admitted on [DATE];
The resident transferred to the hospital on [DATE], with a return anticipated;
No documentation the facility provided the written information to the resident and/or the resident's representative of the ombudsman's contact information, the contact information for the agency responsible for the protective and advocacy of individuals with mental disorders, the contact information for the protection and advocacy of individuals with development disabilities, and the appeal information.
During an interview on 07/31/25 at 11:45 A.M., the Business Office Manager (BOM) and the Social Services Designee (SSD) said the discharge paperwork should include all the required information. The nurses had been using the form in the electronic medical record but it did not have the appeal, ombudsman, or other required information.
During an interview on 07/31/25 at 4:00 P.M., the Administrator said the discharge paperwork did not include all of the required information, but it should.
2. Review of Resident #45’s medical record showed:
admitted on [DATE];
The resident transferred to the hospital on [DATE], with a return anticipated;
No documentation the facility provided the written information to the resident and/or the resident's representative of the ombudsman's contact information, the contact information for the agency responsible for the protective and advocacy of individuals with mental disorders, the contact information for the protection and advocacy of individuals with development disabilities, and the appeal information.
During an interview on 07/31/25 at 10:45 A.M., the Administrator said there was not a transfer/discharge notification form for Resident #45.
Mar 2024
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS, a federally manda...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS, a federally mandated assessment to be completed by the facility staff) for two residents (Resident #28 and #46) out of the 15 sampled residents. The facility census was 60.
Review of the facility's policy titled, MDS 3.0 Care Assessment Summary and Individualized Care Plans, dated 11/06/23, showed:
- The purpose is to understand the changes presented by CMS for the MDS 3.0, to define the intent of each section of the MDS 3.0, and to ensure the MDS 3.0 sections are completed accurately and in a timely manner by the assigned responsible parties;
- Section N is to be completed by nursing staff. This section focuses on the medications the resident has received in the last 7 days or since admission or re-entry if less than 7 days;
- It is used to record the number of days that the resident receives any type of injection insulin and/or specific oral medications.
1. Review of Resident #28's medical record showed:
- An admission date of 03/01/19;
- Diagnoses of hemiplegia (paralysis of one side of the body), hemiparesis (one sided muscle weakness), cerebrovascular disease (a condition that affects blood flow and blood vessels in the brain) and atrial fibrillation (irregular and very rapid heart rhythm that can lead to blood clots);
Review of the resident's Physician Order Sheet (POS), dated March 2024, showed:
- No order for an anticoagulant (a group of medications that decrease the blood to clot);
- An order for clopidogrel (an antiplatelet medicine that keeps platelets in the blood from attaching to each other) and aspirin (an antiplatelet medicine that keeps platelets in the blood from attaching to each other.)
Review of the resident's quarterly MDS, dated [DATE], showed:
- The resident received an anticoagulant on a routine daily basis.
2. Review of Resident #46's medical record showed:
- An admission date of 08/30/22;
- Diagnoses of Alzheimer's (a progressive disease that destroys memory and other important mental functions) disease and unspecified dementia (dementia without a specific diagnosis, mild cognitive impairment).
Review of Resident #46's POS, dated March 2024, showed:
- No order for an antipsychotic (a medication that treats psychosis);
- An order for Namenda (a medication that can treat dementia associated with Alzheimer's disease) and Aricept (a medication that can treat Alzheimer's disease).
Review of the resident's quarterly MDS, dated [DATE], showed:
- The resident received an antipsychotic on a routine daily basis.
During an interview on 03/27/24 the MDS coordinator said:
- At 2:00 P.M., she thought Namenda and Aricept were antipsychotics. He/She was told to use the tabs in the computer that showed the medication was an antipsychotic medication.
- At 3:10 P.M., the MDS coordinator said she was instructed to go by the paper she had with all of the drug classifications on it, not the computer.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement a baseline care plan upon admission with specific interve...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement a baseline care plan upon admission with specific interventions for two residents (Residents #34 and #163 ) out of 15 sampled residents and three residents (Resident #50, #52, and #213) outside the sample. The facility census was 60.
Review of the facility's policy titled, Comprehensive Care Plan and Baseline Care Plans, revised 01/19/22, showed:
- A licensed nurse will coordinate each assessment with the appropriate participation of health professionals, the Interdisciplinary Team (Social Services, Dietary, Physical Therapy, Occupational Therapy, Speech Therapy, Activities and various staff of Nursing);
- The Baseline Care plan must be started upon admission and completed within 48 hours of admission;
- The Baseline Care plan must include: Resident Information, Allergies, Alarms, Bowel and Bladder needs, Cognition, Communication, Diet and Dining Needs, Discharge Planning, Hearing needs, Mood and Behavior, Resident Risks, Medications, Safety, Weight Monitoring needs, Code Status, Physician Orders, Equipment needs, Restorative Needs, Functional Goals, Skin Condition, Social Service Needs, Therapy Needs, and Vision information and needs.
1. Review of Resident #34's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 03/04/24, showed an admission date of 02/27/24.
Review of the resident's medical chart showed no documentation of a baseline care plan with specific interventions completed.
2. Review of Resident #50's MDS, dated [DATE], showed an admission date of 02/13/24.
Review of the resident's medical chart, showed no documentation of a baseline care plan with specific interventions completed.
3. Review of Resident #52's MDS, dated [DATE], showed an admission date of 12/14/23.
Review of the resident's medical chart showed no documentation of a baseline care plan with specific interventions completed.
4. Review of Resident #163's entry tracking record MDS, dated [DATE], showed an admission date of 03/08/24.
Review of the resident's medical chart showed no documentation of a baseline care plan with specific interventions completed.
5. Review of Resident #213's MDS, dated [DATE], showed an admission date of 03/15/24.
Review of the resident's medical chart showed no documentation of a baseline care plan with specific interventions completed.
During an interview on 03/29/24 at 1:26 P.M., the MDS Coordinator said he/she was not aware a baseline care plan needed to be done on new admissions. He/she spoke with the corporate office and was informed that a baseline care plan should be done on all new admissions with specific interventions within 48 hours.
During an interview on 03/29/24 at 1:27 P.M., the Director of Nursing said she had just started employment and was not aware baseline care plans were not being completed on new admissions within 48 hours.
During an interview on 03/29/24 at 1:28 P.M., the Administrator said he would expect a baseline care plan with specific interventions to be completed within 48 hours for each new admission to the facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to limit the use of an as needed (PRN) order for antipsychotic medication (a medication to treat a mental disorder characterized...
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Based on observation, interview, and record review, the facility failed to limit the use of an as needed (PRN) order for antipsychotic medication (a medication to treat a mental disorder characterized by a disconnection from reality) to 14 days for one resident (Resident #10) out of 15 sampled residents. The facility census was 60.
Review of the facility's policy titled, PRN Antipsychotic and Psychotropic Medications, dated 06/29/2023, showed:
- The purpose of the policy and guidelines regarding the use of prn medications orders for psychotropic and antipsychotic drug classifications;
- PRN orders for Anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication;
- Antipsychotic drugs must receive a new order by attending physician or prescribing practitioner every 14 days if they wish to continue the order;
- IF they wish to write a new order for an antipsychotic they must evaluate the resident to determine if the new order for the PRN antipsychotic is appropriate.
1. Review of Resident #10's March 2024 Physician Order Sheet (POS) showed:
- Diagnoses included schizoaffective disorder (a combination of symptoms of schizophrenia, a disorder that affects a person's ability to think, feel, and behave clearly) and mood disorder (affective disorders are described by marked disruptions or emotions);
- An order dated 02/29/24, for Zyprexa (an antipsychotic medication) 5 milligram (mg) one tablet by mouth every 12 hours as needed PRN for agitation.
Review of the resident's Medication Administration Record (MAR), dated March 2024, showed:
- An order, dated 02/29/24, for Zyprexa;
- Zyprexa administered to Resident #10 on 03/25/24, 12 days past the 14 day PRN maximum.
Observations showed:
- On 03/26/24 at 12:15 P.M., the resident reclined in his/her tilt and space wheelchair in the dining room;
- On 03/27/24 at 11:33 A.M., the resident lay in his/her bed with eyes closed;
- On 03/28/24 at 11:45 A.M., the resident sat in his/her wheelchair in the hall near the dining room window;
- On 03/29/24 at 9:00 A.M., the resident lay in his/her bed with eyes closed.
Review of the Pharmacy review note to the physician, dated 03/10/24, showed:
- Please review Zyprexa PRN order for addition of a stop date (14 days) or have a physician or psych progress note for continued use.
During an interview on 3/28/24 at 3:10 P.M., the Director of Nursing (DON) said a PRN 14 day medications should be stopped at the 14th day, or a new order obtained from the physician on the 14th day.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide and document that residents received or declined appropriate immunizations and failed to provide and document pertinent education t...
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Based on interview and record review, the facility failed to provide and document that residents received or declined appropriate immunizations and failed to provide and document pertinent education to residents or resident's representative regarding benefits, side effects or warnings of those immunizations for four residents (Residents #3, #18, #28, and #163) out of the five sampled residents. The facility's census was 60.
Review of the facility's policy titled, Influenza and Pneumococcal Immunizations, revised on 6/30/23, showed:
- The purpose of this policy is to ensure that all residents residing in the facility are offered influenza and pneumococcal immunizations to prevention infection and the spread of communicable diseases;
- The resident or resident representative will be provided education on benefits and potential side effects of both the Influenza and Pneumococcal Immunization;
- The resident or representative will be told the Influenza Immunizations are provided yearly (between October 1 and March 31) unless the immunization is medially contraindicated;
- The resident or representative will be told the Pneumococcal Immunization will be offered upon admission and a second Pneumococcal Immunization may be recommended after five years from the first immunization;
- The resident or representative will be asked to sign the revolving consent form attached to this policy;
- The consent/refusal form will include documentation to support that the resident or their legal representative is fully informed and educated on the benefits and potential side effects of the immunizations;
- Physicians orders will be obtained for the immunizations unless medically contraindicated or the resident or their legal representative has refused the immunizations;
- The resident's clinical record will document:
a. The resident or their legal representative was provided education regarding the benefits and
potential side effects of the influenza and pneumococcal immunizations;
b. The resident either received the influenza and pneumococcal immunizations or did not
receive them due to medical contraindication or refusal.
1. Review of Resident #3's medical record showed:
- admission date of 12/14/23;
- Resident signed revolving consent for refusal of Influenza and Pneumococcal signed and dated 12/14/23;
- Physicians' Order for annual influenza and pneumococcal vaccination dated 1/16/24;
- No documentation of refusal or education for the influenza or pneumococcal vaccination.
2. Review of Resident #18's medical record showed:
- admission date of 1/25/24;
- No record of legal representative consent for Influenza and Pneumococcal vaccination;
- Physicians' Order for annual pneumococcal and influenza vaccination dated 2/19/24;
- No record of annual flu vaccination;
- No documentation of refusal or education for the influenza vaccination;
- No record of pneumococcal vaccination;
- No documentation of refusal or education for the pneumococcal vaccination.
3. Review of Resident #28's medical record showed:
- admission date of 3/1/19;
- Legal representative signed consent for Influenza and Pneumococcal signed and dated 3/1/19;
- Documentation of refusal of influenza and pneumococcal vaccinations undated;
- No documentation of education for the influenza or pneumococcal vaccinations.
4. Review of Resident #163's medical record showed:
- admission date of 3/9/24;
- Physicians' Order for annual influenza vaccination dated 3/14/24;
- No record of annual flu vaccination;
- No documentation of refusal or education for the influenza vaccination.
During an interview on 03/27/24 at 02:01 P.M., the Facility Corporate Nurse said he/she would expect administration or refusals for Influenza and Pneumococcal Vaccinations to be completed for each resident yearly and documented under the immunizations tab of the Electronic Medical Record (EMR).
During an interview on 03/28/24 at 09:53 A.M., the Director of Nursing (DON) said he/she would expect residents to be offered a flu shot annually and refusals to be documented in the medical record.
During an interview on 03/29/24 at 12:12 P.M., the Administrator said he/she would expect Influenza and Pneumococcal Vaccinations to be offered yearly.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to conduct at least twelve hours of nurse aide in-service education per year, failed to provide the required annual competencies of Dementia C...
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Based on interview and record review, the facility failed to conduct at least twelve hours of nurse aide in-service education per year, failed to provide the required annual competencies of Dementia Care (care of a resident with an impaired ability to remember, think, or make decisions) or Abuse Prevention for one out of two nurse aides sampled. The facility census was 60.
1. Review of the facility's 2023 in-service records showed:
- Certified Nurse Aide (CNA) F with a hire date of 01/09/2022;
- CNA F attended a total of one hour and 15 minutes of in-services;
- CNA F did not attend an annual competency in-service on Dementia Care or Abuse and Neglect.
During an interview on 03/28/2024 at 10:26 A.M., the Director of Nursing (DON) said he would be responsible for monitoring the in-services for all staff.
The facility did not provide a policy.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This ...
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Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This deficient practice had the potential to affect all residents. The facility census was 60.
Review of the facility's policy titled, Resident Food Storage, revised 07/05/23, showed:
- The purpose of this policy is to ensure that resident's food storage is safe with sanitary, handling and consumption;
- Food items will be dated after opening.
Observations made on 03/26/24 at 9:44 A.M. and 03/26/24 at 11:47 A.M. of
the kitchen standup freezers, showed:
- A large opened bag of frozen rolls/biscuits undated and not labeled;
- Three bags of miscellaneous frozen breaded patties undated and not labeled;
- A large opened bag of frozen egg omelets undated;
- A large bag of frozen meatballs undated;
- A large opened bag of frozen cinnamon rolls undated;
- A large bag of pepperoni slices undated.
During an interview on 03/26/24 at 11:02 A.M., the Dietary Manager (DM) said he/she would expect all foods to be labeled and dated prior to consumption. He/She was not aware there were food items without a date or a descriptive label in the stand up freezers.
During an interview on 03/27/24 at 10:17 A.M., Dietary [NAME] A said he/she would expect all foods to be labeled and dated prior to consumption.
During an interview on 03/27/24 at 11:32 A.M., the Administrator said he would expect the DM and kitchen staff to have all foods labeled and dated prior to consumption.
Oct 2022
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to complete comprehensive Minimum Data Set assessments (MDS-a federally mandated assessment tool) within the required time frames for five res...
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Based on record review and interview, the facility failed to complete comprehensive Minimum Data Set assessments (MDS-a federally mandated assessment tool) within the required time frames for five residents (Resident #15, #18, #43, #48, and #58) out of 15 sampled residents and one resident (Resident #50) outside of the sample. The facility census was 58.
1. Record review of Resident #15's medical record showed:
- An admission date of 9/26/17;
- A comprehensive Significant Change in Status MDS assessment, dated 10/2/21, with a completion date of 11/24/21;
- No comprehensive Significant Change in Status MDS assessment by the 14th calendar day after the determination that a significant change had occurred.
2. Record review of Resident #18's medical record showed:
- An admission date of 4/19/22;
- A comprehensive admission MDS assessment with a completion date of 5/6/22;
- No comprehensive admission MDS assessment within 14 calendar days of admission.
3. Record review of Resident #43's medical record showed:
- An admission date of 8/10/17;
- An annual comprehensive MDS assessment, dated 7/27/20;
- An annual comprehensive MDS assessment, dated 7/28/21 with a completion date of 10/23/21;
- No comprehensive MDS assessment within 366 calendar days of the last comprehensive MDS assessment.
4. Record review of Resident #48's medical record showed:
- An admission date of 3/23/22;
- A comprehensive admission MDS assessment with a completion date of 4/18/22;
- No comprehensive admission MDS assessment within 14 calendar days of admission.
5. Record review of Resident #50's medical record showed:
- An admission date of 3/2/22;
- A comprehensive admission MDS assessment with a completion date of 3/17/22;
- No comprehensive admission MDS assessment within 14 calendar days of admission.
6. Record review of Resident #58's medical record showed:
- An admission date of 10/14/15;
- A comprehensive annual MDS assessment, dated 10/1/20;
- A comprehensive annual MDS assessment, dated 10/2/21 with a completion date of 11/16/21;
- No comprehensive MDS assessment within 366 calendar days of the last comprehensive MDS assessment.
Record review of the facility's policy titled MDS 3.0, Care Assessment Summary and Individualized Care Plans, revised 2/26/21, showed:
- Purpose: To ensure that MDS 3.0 sections are completed accurately and in a timely manner by the assigned responsible parties;
- MDS's must be kept current and up to date;
- The MDS will be completed within twenty-four (24) hours of the ARD being due.
During an interview on 10/19/22 at 1:47 P.M., the Director of Nursing (DON) and MDS Coordinator said they would expect the RAI manual and facility policy to be followed for completion and submission of every MDS. They would also expect every MDS to be completed and submitted timely.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to electronically transmit significant change and quarterly Minimum Da...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to electronically transmit significant change and quarterly Minimum Data Set assessments (MDS - a federally mandated assessment instrument completed by the facility) in a timely manner and in accordance with guidelines for four residents (Resident #15, #27, #43, and #58) of 15 sampled residents. The facility's census was 58.
Record review of the MDS 3.0 Resident Assessment Instrument (RAI) Manual for assessment transmission showed the following:
- Comprehensive assessments must be transmitted electronically within 14 days of the care plan completion date (V0200C2+14 days);
- All other MDS assessments must be submitted within 14 days of the MDS completion date (Z0500B+14 days).
Record review of the facility's policy titled MDS 3.0, Care Assessment Summary and Individualized Care Plans, revised 2/26/21, showed:
- MDS's must be kept current and up to date;
- MDS's must be transmitted weekly with validation reports printed out and kept within the MDS office for easy access and viewing if needed;
- If MDS's are not transmitted within the correct time frame, payment can be denied for the facility.
1. Record review of Resident #15's medical record showed:
- A comprehensive Significant Change in Status MDS assessment, dated 10/2/21, and completed 11/24/21;
- Care plan decisions for the comprehensive Significant Change in Status MDS assessment completed 11/24/21;
- The comprehensive Significant Change in Status MDS assessment transmitted and accepted 12/9/21 (Validation Report ID #21360829);
- The facility failed to ensure the MDS assessment was transmitted electronically within 14 days of the care plan completion date.
2. Record review of Resident #27's medical record showed:
- A quarterly MDS assessment, dated 8/5/21 and completed 9/9/21;
- The quarterly MDS assessment transmitted and accepted 10/6/21 (Validation Report ID #21062741);
- The facility failed to ensure the quarterly MDS assessment was submitted within 14 days of the MDS completion date.
3. Record review of Resident #43's medical record showed:
- An entry MDS, dated [DATE] and completed 10/14/21;
- The entry MDS transmitted and accepted 10/28/21 (Validation Report ID #21160264);
- The facility failed to ensure the quarterly MDS assessment was submitted within 14 days of the MDS completion date.
4. Record review of Resident #58's medical record showed:
- A comprehensive annual MDS assessment, dated 10/2/21 and completed 11/16/21;
- Care plan decisions for the comprehensive annual MDS assessment completed 11/16/21;
- The comprehensive annual MDS assessment transmitted and accepted 12/9/21 (Validation Report ID #21360829);
- The facility failed to ensure the MDS assessment was transmitted electronically within 14 days of the care plan completion date.
During an interview on 10/19/22 at 1:47 P.M., the Director of Nursing (DON) and MDS Coordinator said they would expect the RAI manual and facility policy to be followed for completion and submission of every MDS. They would also expect every MDS to be completed and submitted timely.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to document a complete and accurate Minimum Data Set (MD...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to document a complete and accurate Minimum Data Set (MDS, a federally mandated assessment completed by the facility) assessments for two residents (Resident #17 and #39) out of 15 sampled residents. The facility's census was 58.
Record review of the facility's policy titled MDS 3.0, Care Assessment Summary and Individualized Care Plans Policy, revised 2/26/21, showed:
- MDS 3.0 sections are to be completed accurately and in a timely manner by the assigned responsible parties.
1. Record review of Resident #17's medical record showed:
- An admission date of 11/22/2011;
- Diagnosis of atherosclerotic heart disease (build-up of cholesterol plaque in the walls of arteries causing obstruction of blood flow).
Record review of the resident's Physician's Order Sheet (POS), dated October 2022, showed:
- An order for Plavix (an antiplatelet medication used to prevent platelets in the blood from sticking together to form blood clots) 75 milligrams (mg) tablet by mouth once daily for atherosclerotic heart disease, dated 1/04/22;
- No order for an anticoagulant (medication that delays or prevents blood clotting).
Record review of the resident's quarterly MDS, dated [DATE], showed:
- Resident received anticoagulant medication;
- The MDS did not reflect an accurate assessment of the resident's medications.
2. Record review of Resident #39's medical record showed:
- An admission date of 3/1/2019;
- Diagnosis of atherosclerotic heart disease.
Record review of the resident's Order Summary Report, dated 10/19/22, showed:
- An order for Plavix 75 mg tablet by mouth one time a day related to atherosclerotic heart disease, dated 7/29/20;
- No current or discontinued order for an anticoagulant.
Record review of the resident's quarterly MDS, dated [DATE], showed:
- Resident received anticoagulant medication for 7 days of the look-back period;
- The MDS did not reflect an accurate assessment of the resident's medications.
During an interview on 10/19/22 at 1:47 P.M., the MDS Coordinator said he/she would not expect a resident with a physician's order for Plavix to be coded as an anticoagulant on the MDS.
During an interview on 10/19/22 at 1:50 P.M., the Director of Nursing said Plavix should not be coded as an anticoagulant on a resident's MDS.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0728
(Tag F0728)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure two nurse aides (NA) completed a nurse aide training program within four months of his/her employment in the facility. This deficien...
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Based on interview and record review, the facility failed to ensure two nurse aides (NA) completed a nurse aide training program within four months of his/her employment in the facility. This deficient practice had the potential to affect all residents in the facility. The facility census was 58.
1. Record review of a Certified Nurse aide (CNA) training report, showed:
- NA A hire date of 2/15/22;
- NA A classroom and on the job training hours completed on 9/21/22;
- NA A approved for CNA final examination and not completed;
- The facility failed to ensure the completion of the program within four months of the hire date.
Observation on 10/16/22 from 11:00 A.M. through 4:00 P.M. showed:
- NA A on the memory unit assisting residents with lunch trays;
- NA A observed on memory unit assisting residents with care needs.
Observations on 10/19/22 from 8:00 A.M. through 1:00 P.M. showed:
- NA A assisting residents with care needs on the 200 hall.
2. Record review of a CNA training report, showed:
- NA B hire date of 10/01/20;
- NA B classroom and on the job training record is incomplete last date signed May 20, 2022;
- NA B training record shows approved for final examination and not completed;
- The facility failed to ensure the completion of the program within four months of the hire date.
During an interview on 10/19/22 at 1:47 P.M., the Administrator and Director of Nursing (DON) said the facility tries to have an NA complete nurse aide training within four months of hire date, but originally had some issues due to the company only allowing two NAs to attend class at a time. The DON said the NA should be certified within four months from date hired into the NA position. The facility has hired hall monitors and moved them into the NA position as class spots become available.
The facility failed to provide a policy for nurse aide training.
Sept 2019
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to date the Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) when Medicare covered services had ended for one resident (Resident ...
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Based on interview and record review the facility failed to date the Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) when Medicare covered services had ended for one resident (Resident #37) and failed to provide two days notice of benefit end date on the SNFABN and Notice of Medicare Non-Coverage (NOMNC) to one resident (Resident #45) out of three sampled residents. The facility census was 52.
1. Review of Resident #37's Notice of Medicare Non-Coverage (NOMNC) showed:
- The resident was discharged from skilled services on 8/29/19;
- The resident remained in the facility;
- The facility failed to date the SNFABN.
2. Review of Resident #45's NOMNC showed:
- The resident was discharged from skilled services on 9/5/19;
- The resident remained in the facility;
- The facility failed to date the SNFABN;
- The facility failed to provide two days notice of service end date
During an interview on 9/25/19 at 4:30 P.M. the Social Services Director said the residents signed the form but the facility failed to date it, she just missed it.
Record review of the facility's policy on Advance Beneficiary Notice of Noncoverage, dated October 2018 showed:
- The forms should be signed and dated by the beneficiary or their representative.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated as...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, for three residents (Resident #1, #13, and #50) out of 13 sampled residents. The facility census was 52.
1. Record review of Resident #1's Medical Record showed:
- A fall on 6/23/19 while attempting to transfer self, no major injuries;
- A fall on 8/13/19 while attempting to get in wheelchair, no major injuries;
Record review of the resident's quarterly MDS, dated [DATE] showed:
- No falls since prior MDS 6/17/19.
2. Record review of Resident #13's Physician Order Sheet (POS), dated 9/15/19 through 10/14/19, showed:
- Diagnosis of Coronary Artery Disease (the narrowing or blockage of the arteries in the heart);
- An order for Aspirin 81 milligrams daily, started on 10/01/18;
Record review of Resident #13's quarterly MDS, dated [DATE], showed:
- Resident is marked as taking an anticoagulant medication (prevents blood clots from forming);
- The resident's MDS did not receive an accurate assessment of medications.
During an interview on 9/25/19 at 3:30 P.M., Licensed Practical Nurse (LPN) B said he/she still includes Aspirin as an anticoagulant on the MDS assessment, although it is not a qualifying medication to be listed as an anticoagulant.
3. Record review of Resident #50's medical chart showed:
- PASARR (Preadmission Screening Resident Review) completed on 3/19/17.
Record review of the resident's MDS, dated [DATE] showed:
- PASARR not marked.
During an interview on 9/26/19 at 10:40 A.M. the Administrator said she would expect the MDS to be marked correctly.
Record review of the facility's policy on MDS, not dated, showed:
- Section A, J, and N is to be completed by nursing staff;
- These sections are to be used to obtain identifying information for the resident that is specific to them and to define the reason for the assessment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review showed the facility failed to ensure professional standards were followed by using another resident's antifungal powder on one resident (Resident #3)...
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Based on observation, interview, and record review showed the facility failed to ensure professional standards were followed by using another resident's antifungal powder on one resident (Resident #3) out of 13 sampled residents. The facility census was 52.
Record review of Resident #3's Physician's Order Sheet (POS), dated 9/15/19 - 10/14/19 showed:
Nystatin powder (antifungal antibiotic used to treat yeast) twice a day as needed.
Observations of Resident #3 on 9/25/19 at 3:13 P.M., showed:
- Certified Nursing Assistant (CNA) C provided incontinent care;
- CNA C applied Phytoplex powder (antifungal powder) to reddened areas under the residents breasts and groin areas.
During interviews on 9/25/19 CNA C said
- At 3:15 P.M., We don't have this powder here, I nabbed it from Hospice.
- At 3:40 P.M., he/she shouldn't have used the Phytoplex powder because it wasn't for Resident #3.
During an interview on 9/25/19 at 3:47 P.M., the Director of Nursing (DON) said the CNA's should not be using antifungal powder because it is considered a treatment and there is an order in place for Nystatin powder twice a day as needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation and interview the facility failed to provide adequate incontinent care of one resident (Resident #46) out of four sampled residents. The facility census was 52.
Record review of R...
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Based on observation and interview the facility failed to provide adequate incontinent care of one resident (Resident #46) out of four sampled residents. The facility census was 52.
Record review of Resident #46's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 9/9/19, showed:
- Always incontinent of bowel and bladder;
- Total dependence of one staff member for toileting.
Observations on 9/25/19, showed:
- At 1:49 P.M., Certified Nursing Assistant (CNA) A and CNA C transferred the resident from the wheel chair to the bed;
- CNA C removed the urine soaked brief;
- CNA C changed gloves and cleaned the front perineal area and groins;
- CNA C changed gloves and cleaned the anal area;
- CNA C did not clean the residents residents buttocks, hips or inner thighs;
- A quarter size brown area observed on the residents left inner buttock;
- At 2:15 P.M., during wound care observation Licensed Practical Nurse (LPN) B cleaned the brown area from the residents left inner buttock.
During an interview on 9/25/19 at 2:20 P.M., LPN B said the brown area she cleaned off was dried stool and it should have been cleaned off during incontinent care.
During an interview on 9/25/19 at 2:25 P.M., CNA C said all areas should be cleaned good.
During an interview on 9/26/19 at 1:02 P.M., the Director of Nursing (DON) said she would expect incontinent care to be more thorough than that and all areas including buttocks, hips and inner thighs should be cleaned.
Review of the facility's Peri-Care Policy, dated April 2017, showed:
- Gently wash the inner legs;
- The policy does not address washing the hips or buttocks.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide appropriate care and treatment necessary to prevent the occu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide appropriate care and treatment necessary to prevent the occurrence of constipation and follow the bowel protocol for one resident (Resident #40) out of 13 sampled residents. The facility census was 52.
1. Record review of Resident #40's Physician's Order Sheet (POS), dated 9/15/19 through 10/14/19 showed:
- An order, dated 10/16/18 for docusate (a stool softener) 100 milligram (mg) one capsule by mouth twice daily;
- An order, dated 10/16/18 for milk of magnesia 30 milliliters (ml) by mouth daily as needed (prn) for constipation.
Record review of the resident's Medication Administration Record (MAR) dated 8/14/19 through 9/15/19 showed:
- An order, dated 10/16/18 for milk of magnesia 30 ml by mouth daily prn:
- No documentation of the resident receiving the medication for 31 days.
Record review of the Certified Nurse Aides (CNA) daily documentation sheets 9/1/19 through 9/15/19 showed:
- No documentation of bowel movements on the days from 9/5/19 through 9/14/19 (10 days).
Record review of the resident's hospital medical record showed:
- The resident admitted to the hospital from [DATE] through 9/18/19.
- Diagnoses of bowel impaction (hardened stool that becomes stuck in the rectum or lower colon due to chronic constipation), abdominal distention (swelling of the abdomen area), and urinary tract infection (infection of the urinary system, kidneys, bladder or urethra).
- A CT (computed tomography) (combines series of x-ray images taken from different angles around the body and uses computer processing to create cross-sectional images of the body) of the abdomen and pelvis showed increase stool in the rectosigmoid (portion of the large intestine before joining the rectum) colon.
During an interview on 9/24/19 at 2:44 P.M., the resident said he/she had complained for a long time about his/her stomach hurting but the staff did not want to do anything. The resident said on 9/14/19 he/she made an emergency call for an ambulance. The resident said he/she was admitted to the hospital for several days and the hospital gave him/her enemas.
During an interview on 9/25/19 at 2:40 P.M., CNA A said it is the responsibility of the CNA's to mark the bowel movements. If the residents do not have a bowel movement in three days the CNA's make a laxative list and give to the nurse.
During an interview on 9/25/19 at 3:00 P.M., the Administrator said after three days, CNA's should be letting the nurse know so the nurse can call and get something ordered for the resident.
During an interview on 9/25/19 at 4:10 P.M., Licensed Practical Nurse (LPN) B said if the resident does not have a bowel movement after three days, the CNA's let the nurse know and usually milk of magnesia is given, encourage water intake, try to wait eight hours, then if that does not work give a Bisacodyl (a gentle laxative), then if that does not work, the physician is notified. LPN B said he/she was not aware of the resident calling for an ambulance until after the resident had made the call. LPN B said he/she was not aware of the resident having any bowel problems.
During an interview on 9/26/19 at 1:15 P.M., the Director of Nursing (DON) said the CNA's make a laxative list for the residents that have not had bowel movements in three days, they give the list to the nurse, the medication technician administers the laxative, if that does not work then the nurse needs to be told, and the physician notified.
The facility did not provide a policy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to provide appropriate treatment and services for care of a Foley catheter (a flexible tube placed into the bladder to drain and ...
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Based on observation, interview, and record review the facility failed to provide appropriate treatment and services for care of a Foley catheter (a flexible tube placed into the bladder to drain and collect urine) collection bag and tubing not placed correctly for one resident (Resident #40) out of one sampled resident. The facility census was 52 .
1. Record review of Resident #40's medical record showed:
- Diagnosis of urinary retention (difficulty urinating and completely emptying the bladder;
- An order for a Foley catheter;
- An order, dated 9/18/19 for cephalexin (an antibiotic) 500 milligram (mg) by mouth three times daily for seven days for urinary tract infection.
Observations of the resident showed:
- On 9/25/19 at 11:43 A.M., 1:15 P.M., 2:31 P.M., the resident propelling self in his/her wheel chair, and the catheter tubing dragging on the floor.
During an interview on 9/26/19 at 1:00 P.M., the Director of Nursing said the resident's catheter tubing should be up off of the floor. She said the hook on the catheter bag had broken and has been replaced.
During an interview on 9/26/19 at 1:05 P.M., the Administrator said the catheter tubing should be secured so it would not drag the floor.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure staff followed hand hygiene practices consistent with accepted standards of practice for one resident (Resident #8) ou...
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Based on observation, interview, and record review, the facility failed to ensure staff followed hand hygiene practices consistent with accepted standards of practice for one resident (Resident #8) out of five sampled residents. The facility census was 52.
Record review of Resident #8's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 7/2/19, showed:
- Cognitive status severely impaired;
- Supervision with encouragement and cueing for meals.
Observations on 9/24/19 at 12:43 P.M., showed:
- Certified Nursing Assistant (CNA) A sat with the resident assisting with meal;
- With the right ungloved hand, CNA A held a fork loaded with chicken;
- With the left ungloved hand, CNA A pulled some of the chicken from the fork before feeding it to the resident;
- With the left hand, CNA A wiped hair from his/her face;
- With the forefinger and thumb of the right ungloved hand, CNA A held a chicken leg up while pulling meat from the bone with a fork;
- CNA A dropped the fork in his/her lap, picked the fork up and continued to feed the resident using the fork.
During an interview on 09/25/19 at 2:01 P.M., CNA A said he/she didn't realize the meat or hair was being touched while feeding the resident and that the fork was used after it was picked up from his/her lap.
During an interview on 9/25/19 at 2:42 P.M., the Director of Nursing (DON) said staff should not touch the residents food with bare hands, touch their own hair while feeding the resident, or use a fork after dropping it in their own lap.
The facility did not provide a policy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to control...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to control the fly population in the facility. This practice had the potential to affect all residents. The facility census was 52.
During a group interview on 9/24/19 at 10:55 A.M., Resident's #19, #21, #25, #29, and #47 collectively said the flies are a big problem in the dining room.
Observation on 9/24/19 at 12:00 P.M. in the unit dining room, showed:
- A fly crawling on Resident #13's silverware;
- A fly crawling on the handle of a one gallon tea pitcher on the drink cart;
- A fly buzzing around the food cart while staff was preparing plates for residents;
- A fly crawling on the rim of a bowl of pureed green peas of Resident #16;
- A fly crawling on the rim of a bowl of lemon pudding of Resident #22;
- A fly crawling on the right elbow of Resident #22;
- No fly control devices noted in unit dining room at this time.
Observation and interview on 9/25/19 at 8:50 A.M. showed:
- Resident #5 carried a plastic fly swatter in to the unit dining room;
- Resident #5 said I'm using it to kill those flies in the dining room.
Observation and interview on 9/25/19 at 11:43 A.M. in the main dining room, showed:
- Resident #29 reclined in his/her geri-chair, near his/her dining room table;
- A fly buzzed around Resident #29's head and landed on his/her right ear;
- Resident #29 tried to raise his/her right arm to [NAME] the fly away;
- Resident #29 only able to raise right arm half way due to a stroke;
- Resident #29 said the flies are bad right now;
- No fly control devices noted in main dining room at this time.
Observation on 9/25/19 at 12:08 P.M. in the unit dining room, showed:
- A fly crawling on the rim of Resident #15's lunch plate while he/she was eating;
- A fly crawling on the dispenser handle of the ice machine.
During an interview on 9/25/19 at 8:52 A.M., Certified Nurse Aide (CNA) D said the flies have been hard to control during the warm weather. They have been trying not to open the door at the end of the hallway any more then necessary, and they have been using fly swatters to try to control them. A pest control company does come in and spray often, but they just can not get rid of them.
During an interview on 9/26/19 at 10:39 A.M., the Administrator said she would not expect the residents to have to eat their meals with flies buzzing around them and landing on their plates and bodies.
Review of the facility's Pest Control Policy, dated 9/9/19, showed:
- It is the policy of Reliant Care Management to provide a safe, clean, homelike environment to all residents;
- If the facility experiences a pest control problem, the facility will take the following steps;
- An electronic Fly Zapper if indicated that is maintained per the manufacturer protocol by the maintenance director or designee;
- Education of staff on the deep cleaning process as indicated to ensure that rooms are being sanitized appropriately;
- Special considerations of electronic Fly Zapper, glue boards should be replaced at least every 90 days and bulbs once a year to maintain quality fly trapping.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0868
(Tag F0868)
Minor procedural issue · This affected most or all residents
Based on record review and interview, the facility failed to maintain quarterly quality assessment committee (QAA) meetings with the required members. The facility's census was 52.
1. Record review of...
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Based on record review and interview, the facility failed to maintain quarterly quality assessment committee (QAA) meetings with the required members. The facility's census was 52.
1. Record review of the second quarter QAA Committee Information, dated 6/10/19, provided by the Administrator showed the following members attended:
- Administrator;
- Director of Nurses;
- Social Services Director;
- Activity Director;
- Certified Medication Technician;
- Resident.
Record review of the third quarter QAA Committee Information, dated 7/1/19, provided by the Administrator showed the following members attended:
- Administrator;
- Director of Nurses:
- Business Office Manager;
- Minimum Data Set (MDS: a federally mandated assessment tool) staff;
- Social Services Director;
- Activity Director;
- Dietary Manager;
- Environmental Services;
- Medical Records/Scheduling;
- Certified Medication Technician;
- Resident.
No documentation of the Medical Director attending the second or third quarter meetings.
During an interview on 9/26/19 at 9:29 A.M., the Administrator said she would expect all department heads and the Medical Director to be there, however since she had only been there a week she did not know who had attended the previous meetings.
During an interview on 9/26/19 at 9:31 A.M., the Business Office Manager said the Medical Director does not attend the QAA meetings. He said the previous Administrator and the Director of Nursing would go over meeting minutes with him.
The facility did not provide a policy.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Missouri facilities.
Concerns
- • 20 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 65/100. Visit in person and ask pointed questions.
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About This Facility
What is Stonecrest Healthcare's CMS Rating?
CMS assigns STONECREST HEALTHCARE an overall rating of 3 out of 5 stars, which is considered average nationally. Within Missouri, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Stonecrest Healthcare Staffed?
CMS rates STONECREST HEALTHCARE's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 52%, compared to the Missouri average of 46%.
What Have Inspectors Found at Stonecrest Healthcare?
State health inspectors documented 20 deficiencies at STONECREST HEALTHCARE during 2019 to 2025. These included: 19 with potential for harm and 1 minor or isolated issues.
Who Owns and Operates Stonecrest Healthcare?
STONECREST HEALTHCARE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by RELIANT CARE MANAGEMENT, a chain that manages multiple nursing homes. With 60 certified beds and approximately 56 residents (about 93% occupancy), it is a smaller facility located in VIBURNUM, Missouri.
How Does Stonecrest Healthcare Compare to Other Missouri Nursing Homes?
Compared to the 100 nursing homes in Missouri, STONECREST HEALTHCARE's overall rating (3 stars) is above the state average of 2.5, staff turnover (52%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Stonecrest Healthcare?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is Stonecrest Healthcare Safe?
Based on CMS inspection data, STONECREST HEALTHCARE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in Missouri. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Stonecrest Healthcare Stick Around?
STONECREST HEALTHCARE has a staff turnover rate of 52%, which is 5 percentage points above the Missouri average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Stonecrest Healthcare Ever Fined?
STONECREST HEALTHCARE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Stonecrest Healthcare on Any Federal Watch List?
STONECREST HEALTHCARE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.