Stonecrest Healthcare

Inspectors wroteBased 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 had the potential to affect all residents. The facility census was 54. Review of the facility's policy titled, Dietary - Receiving and Storing Food and Supplies, revised June 2023, showed: Do not accept and return to the supplier, any item that is: [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an Infection Prevention and Control Program (IPCP) that included an antibiotic stewardship program to include and infection surveillance program and antibiotic use protocols. This deficient practice had the potential to affect all residents in the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain the surety bond (a purchased bond for security of residents' personal funds) for at least one and one half times the average monthly balance of the residents' personal funds for the last twelve consecutive months from July 2024 to June 2025. The facility census was 54. Review of the facility's policy titled Resident Trust, revised 06/12/25, showed:-The facility shall provide assurance of financial security by means of a surety bond;-The bond shall be in an amount equal to at least one and one half times the average total of the reconciled monthly balances;-A copy of the current bond shall be kept in a file in the facility by the Resident Trust Clerk. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to use proper infection control techniques during incontinent care for three residents (Residents #2, #3, and #39) out of three sampled residents, and during catheter (a flexible tube inserted into the bladder to drain urine) care for two residents (Residents # 4 and #5) out of two sampled residents. The facility failed to provide appropriate documentation of tuberculosis (TB - an infectious bacterial disease that affects the lungs) testing for five residents (Residents #1, #2, #7, #10, and #45) out of five sampled residents. The facility census was 54. Review of the facility's policy titled, Infection Prevention and Control Program, dated 06/26/24, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to control the insect population in the facility. The facility census was 54. Review of the facility's policy titled, Pest Control Program Policy, revised 05/14/24, showed:It is the policy of this facility to maintain an effective pest control program (measures to eradicate and contain common household pests (e.g., bed bugs, lice, roaches, ants, mosquitoes, flies, mice and rats) that eradicates and contains common household pests and rodents;Facility will maintain a written agreement with a qualified outside pest service to provide comprehensive pest control services on a regular and scheduled basis;Facility will ensure that appropriate chemicals are used to control pests but can be used safely inside the building without compromising resident health;Facility will [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the correct Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) forms and failed to complete and notify in the proper time frame, at least two calendar days before services ended, for the SNF ABN and the Notice of Medicare Non-Coverage (NOMNC) forms for two residents (Residents #9 and #11) out of three sampled residents whose Medicare services ended and remained in the facility. The facility census was 54. The facility did not provide a policy regarding SNFABN. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to limit the use of an as needed (PRN) psychotropic (medications that affect mental processes and behaviors) medication orders for 14 days unless specific duration and clinical rationale were provided for two residents (Residents #2 and #6) out of two sampled residents. The facility census was 54. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff utilized safe transfer techniques for two residents (Residents #4 and #39) when staff failed to use a Hoyer lift (a mechanical device used to move or transfer a person) out of three sampled residents and to use a gait belt (a canvas belt placed around the resident's waist to assist with ambulation and transfers) appropriately when transferring one resident (Resident #39) out of one sampled resident. The facility failed to ensure quarterly smoking assessments were completed per facility policy for one resident (Resident #39) out of two sampled residents. The facility census was 54. Review of the facility's policy titled Precautionary Measures for Gait Belt Application and Usage, Revised 06/29/23, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a urinary indwelling catheter (a tube inserted into the bladder to drain urine) drainage bag was maintained in the proper position of above the bladder for two residents (Residents #4 and #5) and the facility failed to ensure a catheter drainage bag had a privacy cover for one resident (Resident #5) out of two sampled residents. The facility also failed to ensure one resident (Resident #3) received appropriate treatment and services after an incontinent episode which left the resident in a urine saturated brief with a strong urine odor out of three sampled residents who were incontinent of bladder. The facility census was 54. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent (%) when medications were administered. There were 32 opportunities with two errors made, for an error rate of 6.25%. This practice affected two residents (Residents #7 and #15) of five sampled residents. The facility census was 54. Review of the facility's policy titled, Medication Administration, last revised 06/26/24, showed: [...]

Inspectors wroteBased 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; [...]

Inspectors wroteBased 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; [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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; [...]

Inspectors wroteBased 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; [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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; [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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: [...]