Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Stonecrest Healthcare during CMS and state inspections, most recent first.
Unsanitary Food Storage and Kitchen Conditions: The kitchen had multiple sanitation and storage failures, including a sewer gas odor, high room temperature, a dishwasher that did not register sanitizer, debris and grime on floors, equipment, and shelves, uncovered food cups and desserts, and dirty ice machine, refrigerator, microwave, and can opener surfaces. Dry storage also contained a dented can, an unlabeled oatmeal bin, an unsealed thickening powder box, and an opened sack of oatmeal stored too low, with scattered debris and damaged shelving noted throughout.
Incomplete Antibiotic Stewardship and Infection Surveillance Documentation: The facility failed to maintain an IPCP that included an antibiotic stewardship program with infection surveillance and antibiotic use protocols. The policy required tracking antibiotic prescribing practices, reviewing the Infection Log in PCC, and using an Antibiotic Utilization Report, but the Infection Control binder had no infection surveillance documentation for 2024 or 2025. The PCC Infection Surveillance log also had widespread missing entries for infection type, site, signs and symptoms, precautions, organisms, and lab documentation, while the DON/IP and Administrator stated all required documentation should be included.
Insufficient Surety Bond for Resident Personal Funds: The facility failed to maintain a surety bond equal to at least 1.5 times the average monthly balance of residents’ personal funds. Records showed the approved bond was $52,000.00, while the average resident trust balance required a bond of at least $190,500. The BOM and Administrator both stated the bond amount should have been higher and was currently too low.
The facility failed to use proper infection control practices during incontinent care and catheter care, with CNAs and an RN repeatedly missing hand hygiene, reusing washcloth areas, changing gloves inconsistently, and handling soiled and clean items without proper technique. The facility also lacked required TB testing documentation for several residents, including annual TSTs without read dates and one resident with no documentation of the required two-step TST.
Ineffective pest control program with roaches and flies observed in kitchen and resident areas. The facility had no pest activity log or reporting system, and pest control invoices showed gaps in service and no documentation that flies were targeted. Surveyors observed roaches in the kitchen food prep area and flies in the kitchen, 300 Hall, unit dining area, and resident rooms. Staff reported the pests had been present for days to weeks, had been verbally reported to management, and residents said the flies were frustrating during meals and were always present.
The facility did not provide two residents and/or their representatives with written information regarding ombudsman contact details, advocacy agencies, and appeal rights during hospital transfers. Staff interviews confirmed that the discharge paperwork and electronic forms lacked these required elements.
The facility failed to issue the correct SNF ABN form and failed to give the SNF ABN and NOMNC at least two calendar days before Medicare skilled services ended for two residents who remained in the facility. Records showed both residents received the forms on the same day their skilled Medicare services ended, and interviews noted the prior SSD did not do things correctly while the new SSD was still in training.
PRN psychotropic medication orders were not limited to 14 days for two residents. One resident with dementia, anxiety, vascular dementia with behavioral disturbance, and schizoaffective disorder had PRN lorazepam orders without stop dates, and another resident with Alzheimer's disease, depression, panic disorder, bipolar disorder, and a hx of suicide attempt had PRN lorazepam and diazepam orders without stop dates. The record lacked documentation for extending these PRN orders beyond 14 days, and the DON and Administrator stated that PRN psychotropics should have a 14-day stop date or a clinical rationale for a longer duration.
Staff failed to use safe transfer techniques for two residents who were dependent for transfers, including transferring one resident without a gait belt and using axillary holds and waistband lifting instead of the ordered mechanical lift method. Staff also failed to complete quarterly smoking assessments for a resident with tobacco use, while observations showed staff assisting with smoking and the resident not using a smoking apron or other smoking interventions.
Inadequate catheter care and incontinent care: A resident who was always incontinent was found in a urine-saturated brief with a strong urine odor, and a urine-saturated pillow and pillowcase in the wheelchair were not changed or cleaned during care. Two residents with indwelling catheters had drainage bags and tubing placed improperly, including tubing on the floor, a bag held above bladder level during transfer, and a drainage bag without proper privacy coverage, contrary to the facility’s catheter care policy.
Medication Administration Error Rate Exceeded 5%: Surveyors observed 32 medication administration opportunities and found 2 errors, resulting in a 6.25% error rate. Two residents were affected when a CMT failed to administer ordered meds, including oxybutynin ER for a resident with COPD, vascular dementia, and other diagnoses, and a COPD inhaler for a resident with COPD, depression, anxiety, fibromyalgia, and osteoarthritis. The CMT said the meds had not been delivered from the pharmacy, and one resident's inhaler had not been given for two weeks and was not reported to the DON.
Unsanitary Food Storage and Kitchen Conditions
Penalty
Summary
The facility failed to store and distribute food under sanitary conditions. During observations of the kitchen, the water temperature at the three-compartment manual dishwashing sinks was 100 F, the room temperature was 84 F, and there was a sewer gas odor near the reach-in refrigerators and staff bathroom. The commercial dishwasher liquid did not register on the chemical test strip, and there was an unsealed window air-conditioner unit with gaps around three edges. The floor below the reach-in freezer, reach-in refrigerator, range, and ice machine had scattered debris, oily film, and brown grime, and the ice machine had white buildup on the exterior and black grime on the interior plastic surface. Additional kitchen observations showed a commercial style can opener with an oily film on the blade, a reach-in refrigerator with scattered food debris on the shelves, a microwave oven with food debris buildup and a chipped surface, and a dishwasher with white buildup on the exterior. The floor and plumbing pipes below the dishwashing area counters and three-compartment sinks had scattered debris, oily film, and brown grime buildup. Uncovered food items were also observed, including trays of individual dessert gelatin bake cups and trays of milk and lemonade cups. Ceiling diffuser surfaces had dust buildup and a brown substance, and a cracked plastic light fixture cover and a non-intact wall section without a baseboard were also observed. In the dry food storage area, a 3-quart fruit pie filling can had a 3-inch dent, an opened 25-pound box of thickening powder had an unsealed plastic liner, a partially full 5-gallon storage bin of oatmeal was undated and unlabeled, and an opened 50-pound sack of oatmeal was loosely folded and stored less than 4 inches from the floor. Scattered food debris was present on the floor and along the walls below the food shelves, and the painted wooden shelves were scuffed and peeled with a bottom shelf approximately 4 inches above the floor. The Maintenance Director, Dietary Manager, and Administrator each acknowledged the sewer gas odor, the poor kitchen cooling, the dirty floors and equipment, the uncovered and improperly stored food items, and the need for better storage conditions and cleaning.
Incomplete Antibiotic Stewardship and Infection Surveillance Documentation
Penalty
Summary
The facility failed to maintain an Infection Prevention and Control Program that included an antibiotic stewardship program with an infection surveillance program and antibiotic use protocols. Review of the facility policy titled, Antibiotic Stewardship Program, showed that the facility was expected to track and monitor antibiotic prescribing practices and resistance patterns, review and audit the Infection Log weekly in PCC, and use an Antibiotic Utilization Report to collect and track antibiotic usage, including resident name, antibiotic name, indication, route, dose, prescribed length of therapy, prescriber, and prescribing facility. The policy also stated that the Facility Antibiotic Steward would track antibiotic time-outs, recommended actions for ongoing treatment needs, syndrome-specific antibiotic use and prophylaxis, and multi-drug-resistant infections. Review of the Infection Control binder showed no documentation of infection surveillance for 2024 or 2025. Review of the facility matrix dated 07/28/25 showed two residents currently receiving antibiotics. Review of the PCC Infection Surveillance log dated 07/01/24 - 07/31/25 showed missing documentation in most entries, including no infection type for 169 of 184 entries, no infection site for 166 of 184 entries, no signs and symptoms for 167 of 184 entries, no precautions for 173 of 184 entries, no organisms for 183 of 184 entries, and no lab documentation. During interviews, the DON/Infection Preventionist and the Administrator stated that all required documentation should be included in the antibiotic stewardship and infection tracking.
Insufficient Surety Bond for Resident Personal Funds
Penalty
Summary
Assure the security of all personal funds of residents deposited with the facility was deficient because the facility did not maintain a surety bond in an amount equal to at least one and one half times the average monthly balance of residents’ personal funds for the last twelve consecutive months from July 2024 to June 2025. Review of the facility’s Resident Trust policy showed the facility was required to provide financial security by means of a surety bond, with the bond amount equal to at least one and one half times the average total of the reconciled monthly balances, and to keep a copy of the current bond on file. Record review showed the facility’s approved bond amount was $52,000.00, while the average monthly balance of residents’ personal funds was $127,499.59, requiring a bond of at least $190,500. During interviews, the BOM and Administrator both stated the bond should have been one and one half times the average resident trust balance and that the current bond amount was too low.
Infection Control and TB Testing Documentation Failures
Penalty
Summary
The facility failed to use proper infection control techniques during incontinent care for three residents and during catheter care for two residents. During incontinent care for one resident, two CNAs and an RN did not perform hand hygiene at multiple points, reused the same washcloth area on the groin and buttocks, changed gloves inconsistently, and applied Calmoseptine to an open area on the buttocks and coccyx without hand hygiene before or after the task. During incontinent care for another resident, two CNAs transferred the resident while the wheelchair cushion and clothing were saturated with urine, used the resident’s own hand to wipe the peri area, reused the same washcloth areas on the peri area and buttocks, did not clean all urine-exposed areas, handled soiled linens and clean supplies without hand hygiene, and placed the resident back onto a urine-saturated pillow and pillowcase without changing or cleaning them. During incontinent care for a third resident, two CNAs performed care with fecal material present, reused the same wipe areas multiple times on the buttocks and groin, changed gloves without hand hygiene, and handled the wheelchair cushion and room surfaces without consistent hand hygiene. The facility also failed to follow catheter care practices for two residents. For one resident with a suprapubic catheter, CNAs entered the room without hand hygiene, lowered clothing and the brief, cleaned the catheter tubing with a twisting motion from the insertion point down, did not clean the full peri area, moved the drainage bag between surfaces and onto a CNA’s scrub pants pocket, and handled clean and soiled items without hand hygiene. For another resident with a catheter, CNAs did not perform hand hygiene before care, placed the drainage bag on the floor and then on a CNA’s scrub pants, removed the brief and pants, cleaned the groin and perineal area without changing gloves or performing hand hygiene, and cleaned the catheter from the insertion point down twice with the same area of the washcloth. The facility failed to provide appropriate documentation of TB testing for five residents. One resident had an annual TB screening documented with a negative result but no read date. Another resident had two annual TB screenings documented with negative results and no read dates. Two additional residents also had annual TB screenings documented with negative results and no read dates. One resident had no documentation that the required two-step TST was administered. Facility policy and state guidance in the record stated that TB testing should be documented, including read dates, and that TST results should be read within the required time window.
Ineffective pest control program with roaches and flies observed in kitchen and resident areas
Penalty
Summary
The facility failed to maintain an effective pest control program to control the insect population in the building. The facility census was 54. Its written Pest Control Program Policy stated that the facility would maintain an effective pest control program, keep a written agreement with a qualified outside pest service, use chemicals safely inside the building, maintain a report system for issues between scheduled visits, and use a variety of methods to control seasonal pests such as flies. However, review of 2025 pest control invoices showed no service invoices for January, May, and June, and the documented services in February, March, and April targeted roaches. July showed an initial service with a new provider, and there was no documentation that services targeted flies. The facility also had no documentation of a system or log for staff to report pest activity. During observations in the kitchen, surveyors saw 12 roaches crawling and six flies flying around the food preparation area, under the three-compartment sink, near dishwashing liquid containers, and near a non-intact wall section beside the can opener and plastic utensil drawers. Dietary staff reported that roaches had been a problem near the dishwasher, had been seen for the last several days or weeks, and that the Dietary Manager had been made aware of the problem. Staff also stated the kitchen had been sprayed, but the bugs came back. Surveyors also observed flies in the 300 Hall and unit dining area, including one dead fly on the ice dispenser and 12 flies landing on tables, residents, resident food trays, privacy curtains, and floors. Staff stated there was no monthly reporting system or pest log, that nursing had been verbally advised about the flies or bugs, and that flies were common in the hall, dining area, hallway, and resident rooms. Residents reported that flies were frustrating during meals and were always present in the dining area, hall, and rooms. The Maintenance Director, Dietary Manager, and Administrator acknowledged awareness of roaches and flies in the kitchen and dining areas, and the Administrator stated it was apparent the bugs were still a problem.
Failure to Provide Required Written Transfer/Discharge Information
Penalty
Summary
The facility failed to provide required written information to residents and/or their representatives regarding ombudsman contact details, agencies responsible for protection and advocacy for individuals with mental disorders and developmental disabilities, and appeal rights. This deficiency was identified for two residents who were transferred to the hospital with an anticipated return. Review of the facility's policy indicated that such information should be included in the transfer/discharge paperwork, but documentation was lacking in both cases. Interviews with facility staff, including the Business Office Manager, Social Services Designee, and Administrator, confirmed that the discharge paperwork used did not contain the necessary information. The electronic medical record form utilized by nurses omitted the appeal, ombudsman, and other required contact details. There was also no transfer/discharge notification form present for one of the residents, further evidencing the failure to meet regulatory requirements.
Failure to Provide Correct Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide the correct Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) forms and failed to complete and notify residents in the proper time frame, at least two calendar days before services ended, for two residents whose Medicare skilled services ended and who remained in the facility. The facility census was 54, and the report identified two affected residents out of three sampled residents whose Medicare services ended and who stayed in the facility. For Resident #9, the medical record showed discharge from Medicare skilled services on 02/28/25, with the ABN and NOMNC forms provided on the same date. The facility failed to issue the correct SNF ABN form and failed to provide both the SNF ABN and NOMNC at least two calendar days before skilled Medicare services ended. For Resident #11, the medical record showed discharge from Medicare skilled services on 05/09/25, with the ABN and NOMNC forms provided on the same date, and the facility again failed to issue the correct SNF ABN form and failed to provide both forms at least two calendar days before services ended. During interviews, the BOM stated the previous SSD did not do things correctly, the SSD said he/she was new and still in training, and the Administrator stated she would expect the correct form to be used and the forms to be provided in the correct time frame.
PRN Psychotropic Orders Lacked Required 14-Day Limits
Penalty
Summary
The facility failed to limit PRN psychotropic medication orders to 14 days unless a specific duration and clinical rationale were documented for two residents. Review of the facility policy titled, Use of Psychotropic Medication Policy, showed that PRN psychotropic drugs are to be used only for a diagnosed specific condition and for a limited duration of 14 days, unless the prescribing practitioner documents a rationale for extending the order and indicates the duration. The facility census was 54, and the deficiency involved two of two sampled residents. One resident had diagnoses including dementia, anxiety, vascular dementia with behavioral disturbance, and schizoaffective disorder, bipolar type, and had PRN lorazepam orders for anxiety, shortness of breath, and agitation/anxiety with no stop date. The medical record contained no documentation supporting a greater than 14 day time frame for those orders, and the facility did not provide a 14 day stop date. Another resident had diagnoses including Alzheimer's disease, nontraumatic subdural hemorrhage, insomnia, major depressive disorder, suicide attempt, panic disorder, and bipolar disorder, and had PRN lorazepam and diazepam orders for anxiety/agitation with no stop date. The medical record also lacked documentation for extending those PRN orders beyond 14 days, and the facility did not provide a 14 day stop date. The DON and Administrator stated that PRN psychotropic medications should have a 14 day stop date or a clinical rationale for a longer order.
Unsafe Transfers and Missed Smoking Assessment
Penalty
Summary
Staff failed to use safe transfer techniques for two residents during observed transfers. One resident had diagnoses including heart failure, muscle weakness, lack of coordination, and weakness, and the quarterly MDS showed severely impaired cognition, bilateral lower extremity functional impairment, dependence for chair/bed-to-chair transfers, and substantial to maximal assistance for bed mobility. The resident’s care plan identified high fall risk, but did not address how staff were to transfer the resident. During observation, two CNAs transferred the resident from the side of the bed to the wheelchair without a gait belt, placed their forearms under the resident’s axillary areas, held the back waistband of the resident’s pants, lifted and pivoted the resident while the resident did not bear weight, and placed the resident into the wheelchair. A second resident had diagnoses including right-sided hemiplegia, scoliosis, traumatic brain injury, unsteadiness on feet, abnormal posture, multiple contractures, and tobacco use. The quarterly MDS showed moderate cognitive impairment, ROM limitations, and dependence for chair/bed-to-chair transfers. The care plan stated the resident was totally dependent on two staff for transferring, but did not address how to transfer the resident. During observation, staff wrapped a gait belt loosely around the resident’s lower chest or upper abdomen rather than positioning it appropriately, and two CNAs repeatedly placed their arms under the resident’s axillary areas and used the waistband of the resident’s pants to assist with transfers between the wheelchair and bed. The resident’s right foot had to be manually turned during one transfer. The facility also failed to complete quarterly smoking assessments per policy for the resident with tobacco use. The resident’s admission MDS showed no current tobacco use, while the quarterly MDS listed tobacco use. During observations in the smoking area, staff assisted the resident with smoking, including holding an ashtray up to the resident, lighting cigarettes, and repositioning the resident with a pillow while the resident leaned to the right. The resident did not wear a smoking apron or use smoking interventions during the observed smoke breaks. In interview, the resident said no smoking apron was used, and a CNA stated the resident never used one, while later stating the resident may need one but had pulled it off previously. The DON and Administrator stated smoking assessments should be completed quarterly and reflect the resident’s safety needs.
Inadequate catheter care and incontinent care
Penalty
Summary
The facility failed to provide appropriate catheter care and appropriate care to prevent urinary tract infections for residents with indwelling catheters, and failed to provide appropriate care for an incontinent resident after an episode of urinary incontinence. The report identified that catheter drainage bags were not maintained below the level of the bladder for two residents, and one resident’s catheter drainage bag did not have a privacy cover in place. The facility policy stated that catheter care was to be performed every shift and as needed, privacy bags were to be available and used at all times, and drainage bags were to be located below the bladder to discourage backflow of urine. One resident had diagnoses including intracranial injury with loss of consciousness, quadriplegia, cerebral infarction, lack of coordination, muscle weakness, UTI, hemiplegia, and hemiparesis. The resident was dependent for toileting and personal hygiene and always incontinent of bowel and bladder. During observation, the resident was found in a urine-saturated brief with a strong urine odor, and a urine-saturated pillow and pillowcase were present in the wheelchair seat. Staff provided incontinent care, but the urine-saturated pillowcase was not changed and the pillow in the wheelchair seat was not cleaned and dried or replaced. The resident stated he/she had not been checked or changed since being gotten up that morning before breakfast. Another resident had diagnoses including inflammatory disease of the prostate, gross hematuria, and UTI, and used a suprapubic catheter. Observations showed catheter tubing lying on the floor while the resident was in a wheelchair and in bed, with the drainage bag at times placed on the mattress, hooked to staff clothing, and later hung under the wheelchair seat with tubing touching the wheelchair wheel and dragging on the floor. During transfer, the drainage bag was held above the resident’s bladder and then placed under the wheelchair seat with tubing still on the floor. A third resident with urinary retention and a Foley catheter was observed with catheter tubing lying on the floor and no privacy cover at one point, and later with the drainage bag resting on the floor and the privacy drape not covering the bottom of the bag, allowing the bottom and spout to rest on the floor. Staff interviews confirmed that catheter drainage bags should remain below bladder level, should not touch the floor, and should be covered.
Medication Administration Error Rate Exceeded 5%
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% during medication administration. Surveyors observed 32 medication administration opportunities and identified 2 errors, resulting in an error rate of 6.25%. The deficiency affected two of five sampled residents, and the facility census was 54. The facility policy titled Medication Administration required medications to be administered by authorized staff as ordered, with the medication source compared to the MAR to verify the resident name, medication name, form, dose, route, and time. Resident #7 had diagnoses including COPD, nontraumatic subdural hemorrhage, generalized anxiety disorder, lack of coordination, and vascular dementia. The resident had an order for oxybutynin chloride ER 10 mg by mouth daily, but during observation the CMT failed to administer the medication. Resident #15 had diagnoses including COPD, major depressive disorder, generalized anxiety disorder, fibromyalgia, and osteoarthritis. The resident had an order for fluticasone furoate-vilanterol inhaler 200/25 mcg, one puff daily with mouth rinse after use, but during observation the CMT failed to administer the inhaler. The CMT stated both medications had not been delivered from the pharmacy, and said Resident #15's inhaler had not been given as ordered for two weeks and had not been reported to the DON. The DON stated she was unaware of any medications not being available as ordered, and the Administrator stated all medications should be at the facility and administered as ordered.
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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.
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Nursing homes near Viburnum
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Belleview Valley Nursing Home | 20.1 mi | — | 14 | 1 |
| Steelville Senior Living | 21.2 mi | ★★★★★ | 2 | 0 |
| Salem Care Center | 22.6 mi | ★★★★★ | 0 | 0 |
| Potosi Manor | 23.8 mi | ★★★★★ | 0 | 0 |
| Seville Care Center | 24.1 mi | ★★★★★ | 4 | 0 |
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