Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Stonecreek Health And Rehabilitation during CMS and state inspections, most recent first.
Dietary staff failed to ensure an aide with a beard and mustache wore a facial hair covering while handling and preparing food. The aide was observed removing rolls from the oven and buttering them without the required covering, and he stated he forgot to put one on before working with food. The Dietary Mgr and Administrator confirmed staff were expected to wear the appropriate hair coverings during food prep.
Urinary catheter drainage bags were observed resting on the floor for two residents with indwelling catheters. One resident was cognitively intact and frequently incontinent of bowel, and his bag was repeatedly seen on the floor during care and routine checks. Another resident with severe cognitive impairment also had his catheter bag on the floor during two observations. Staff, the DON, and the PA stated the bags should be below bladder level but not touching the floor.
Medication Error Rate Exceeded Allowed Threshold: A resident with anemia, muscle weakness, and depression received medication pass errors when an MA omitted an ordered B Complex supplement and gave only one tablet of Sertraline 25 mg instead of the ordered three tablets plus a 100 mg tablet. The MA stated she missed the B Complex on the MAR and did not notice the full Sertraline dose; the DON stated the usual process was to compare the medication cards to the MAR before administration, and the PA stated medications should be given as ordered.
Failure to Change Gloves and Perform Hand Hygiene During Incontinence Care: An NA failed to remove dirty gloves or perform hand hygiene while providing incontinence care to a resident with stool present. While cleaning the resident, the NA opened the door, reached into a linen cart, handled clean supplies, and continued care before removing gloves and sanitizing hands. The IP and DON stated gloves should have been removed and hands cleaned before continuing care or obtaining supplies.
A resident with severe cognitive impairment who underwent ORIF surgery for a right elbow fracture did not receive an ordered OT evaluation and treatment due to a failure in communicating the referral from the Orthopedic Surgeon. The splint was not removed for hygiene or ROM as directed, leading to the development of pressure ulcers, exposure of surgical hardware, and infection requiring surgical intervention and IV antibiotics. The breakdown in process for handling outside provider orders and documentation resulted in significant harm.
A resident with severe cognitive impairment suffered a right elbow fracture and underwent ORIF surgery. After returning to the facility, staff failed to document assessments of the surgical site and did not process or communicate an order for OT to address range of motion, pain, and splint management. The resident's follow-up appointment was delayed, and no guidance was sought from the orthopedic surgeon during this period. When finally evaluated, a stage 4 pressure injury with exposed hardware was discovered, requiring emergent surgery and IV antibiotics.
Surveyors found that expired food items, including pre-packaged celery and bread, were not removed from storage, and food storage bins for flour, sugar, and rice were not labeled with use by dates or cleaned as required. Scoop holders attached to these bins contained food debris, and the Dietary Manager was unable to confirm when they were last cleaned. The Administrator acknowledged that expired food should have been disposed of and proper labeling and cleaning should have occurred.
A resident with dementia and recent joint replacement surgery was admitted with two mid-spine pressure ulcers, but the admitting nurse failed to document or report the wounds, resulting in a delay in obtaining physician orders and initiating wound care for two days. The wounds were only identified and treated after intervention by the wound care nurse, with no wound care provided or documented during the initial period.
Nursing staff left medications at the bedside for two cognitively intact residents without documented self-administration assessments. In both cases, nurses failed to observe the residents taking their medications, and facility leadership confirmed that this practice was not in accordance with policy. The responsible staff could not explain why medications were left unsecured, and the required assessments for self-administration were not present in the medical records.
Dietary Aide Failed to Wear Facial Hair Covering During Food Preparation
Penalty
Summary
The facility failed to ensure a Dietary Aide with facial hair wore a facial hair covering while handling and preparing food in the kitchen. On 6/16/26 at 11:19 AM, Dietary Aide #1 was observed removing a tray of rolls from the oven, placing the tray on a workstation, and applying butter to the rolls while not wearing a facial hair covering. The aide had a beard and mustache with facial hair approximately a quarter of an inch in length. During an interview at 11:21 AM, the aide stated he knew he should have been wearing a facial hair covering and forgot to put one on before handling food. The Dietary Manager confirmed at 11:22 AM that the aide should have been wearing a facial hair covering and that dietary staff were expected to wear the appropriate hair covering while preparing food. The Administrator later stated that staff should wear the appropriate hair coverings whenever involved in food preparation to prevent food contamination.
Urinary catheter drainage bags were left on the floor
Penalty
Summary
The facility failed to keep urinary catheter drainage bags from touching the floor for two residents with indwelling catheters. Resident #2 was admitted with obstructive and reflux uropathy and had a suprapubic urinary catheter ordered and care planned with the intervention to keep the bag below bladder level. He was cognitively intact and frequently incontinent of bowel. During multiple observations, his catheter bag was seen lying flat on the floor beside his bed, including during an incontinence care episode when a nurse aide walked past the bag without moving it off the floor. Resident #2, his family member, and staff all described that the catheter bag was not consistently kept off the floor. The resident and family member stated staff did not always notice or reposition the bag, and the resident reported that some staff would hook it to the bed frame when they noticed it on the floor while others would ignore it. A nurse aide stated she did not notice the bag on the floor during care, while another nurse stated she had seen it on the floor earlier and hooked it to the bed frame. The DON and PA both stated the bag should be below bladder level but not on the floor. Resident #72 had obstructive uropathy, severe cognitive impairment, and an indwelling urinary catheter with a care plan addressing catheter management and prevention of UTI and urethral trauma. On two observations, his bedside drainage bag was positioned below bladder level but the catheter bag was resting on the floor. A nurse aide and a nurse both stated catheter bags should not touch the floor because of contamination and germs. The DON and Administrator also stated the drainage bag should be hung on the bed frame below bladder level and not touching the floor.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
Medication error rates were not maintained below 5 percent. Based on record review, observations, and interviews with staff and the Physician Assistant, the facility had 2 medication errors out of 33 opportunities, resulting in a 6.06% medication error rate for 1 of 4 residents observed during medication pass. The errors involved Resident #100, who was admitted with diagnoses including anemia, muscle weakness, and depression, and had active orders for B Complex Plus Vitamin C one tablet daily and Sertraline 25 mg, 3 tablets daily, to be administered with a 100 mg tablet for a total dose of 175 mg. During the medication pass, Medication Aide #1 prepared 6 pills for Resident #100, including Calcium, Losartan, Memantine, Nebivolol, Sertraline 100 mg, and Sertraline 25 mg, but did not include the ordered B Complex Plus Vitamin C. The medication cup was labeled and stored in the medication cart while the resident finished eating breakfast, then later administered. When questioned, MA #1 stated she did not realize the B Complex was omitted and said she must have skipped over it on the MAR because it was at the top. She also stated she did not notice that the Sertraline 25 mg order required three tablets and gave only one tablet instead. The DON stated the usual process was to compare the medication cards to the MAR before pulling and administering them, and the Physician Assistant stated the medications should be given as ordered.
Failure to Change Gloves and Perform Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to implement its infection control policies when Nurse Aide #2 did not change gloves or perform hand hygiene during incontinence care for Resident #2. The facility policy titled Hand Hygiene, implemented on 1/2/26, required hand hygiene after handling contaminated objects, after handling items potentially contaminated with body fluids or excretions, and when moving from a contaminated body site to a clean body site during resident care. During an observation of incontinence care on 6/15/26 at 1:03 PM, Nurse Aide #2 was seen cleaning stool from Resident #2’s buttocks while wearing gloves and a gown. After using at least three washcloths, she walked toward the door without removing her gloves, opened the door, reached into a linen cart positioned in front of the room, obtained a clean drawsheet, and placed it under the resident while removing the old drawsheet. She then rolled the resident onto his back, applied a new pull-up, replaced the covers, and readjusted the bed before placing the dirty washcloths in a plastic bag. She removed her gown and gloves only after completing care and then used hand sanitizer. In interview, Nurse Aide #2 stated she should have removed her gloves and performed hand hygiene after cleaning the stool but became nervous while being observed and forgot. The Infection Preventionist and DON both stated that dirty gloves should have been removed and hands cleaned before continuing care or obtaining supplies.
Failure to Communicate and Implement OT Referral After Orthopedic Surgery
Penalty
Summary
A facility failed to communicate and implement an Occupational Therapy (OT) referral ordered by an Orthopedic Surgeon for a resident who had undergone open reduction internal fixation (ORIF) surgery for a right olecranon fracture. The OT referral, which included instructions for range of motion (ROM), pain and edema control, a home exercise program, and splint removal for hygiene and active ROM, was not relayed to the therapy department. The referral order was scanned into the resident's electronic health record under a different tab from other orthopedic information, resulting in it not being reviewed or acted upon by nursing or therapy staff. The resident, who had severe cognitive impairment and required maximal assistance with upper body dressing and personal hygiene, did not have her splint removed or receive OT evaluation and treatment as ordered. The splint remained in place for nearly two months, and the resident was not evaluated by OT until over three months after the initial referral. During this period, the resident developed two pressure ulcers on the right elbow, one of which exposed surgical hardware and became infected, ultimately requiring surgical intervention for hardware removal and intravenous antibiotics for MRSA. Interviews with facility staff, including the DON, Therapy Director, and Medical Director, confirmed that the OT referral was not communicated or implemented due to breakdowns in the process for handling outside provider orders and documentation. The Orthopedic Surgeon and Therapy Director both stated that the resident should have received OT services as ordered, and the lack of therapy and splint removal contributed to the development of pressure wounds and infection. The deficiency affected one resident reviewed for therapy and resulted in significant harm.
Removal Plan
- Administrator and Director of Clinical Services reviewed all resident orders with outside appointments to ensure they were in place and correct.
- Therapy Director completed an audit of all current facility residents with therapy orders to ensure the correct physician ordered treatment was in place.
- Ad Hoc QAPI meeting conducted to review and determine root cause of the deficient practice.
- Education implemented on who will be responsible for ensuring the referral form is brought back to the facility when a resident has an outside appointment so new recommendations or orders can be implemented.
- Unit Manager will be responsible for ensuring the referral form returns with the resident; if it is the weekend or after hours, the hall nurse will be responsible.
- Transporter will notify the Unit Manager the resident is back from the appointment and will give her any paperwork at that time.
- If there is no referral form, the Unit Manager will call the physician office to obtain a copy of the form.
- Director of Clinical Services provided education to the Administrator, DON, Transportation driver and ADON on new procedures for handling outside appointment paperwork and therapy referrals.
- Unit manager, or designee, will be responsible for entering orders and ensuring any therapy referrals are received by therapy.
- DON will have a list of resident appointments and will follow up with the Unit Managers to ensure all referral forms have been returned and reviewed, with any new orders entered into the medical record.
- Nurse Aides that accompany a resident to an outside appointment are there to care for the resident; the Transportation Driver will be responsible for ensuring any paperwork, and the referral form, are returned to the Nurse Manager or hall Nurse.
- Unit Manager was educated that when a family member signs the resident out for an outside appointment, they are to follow up with the family when they sign the resident back into the facility to ensure all paperwork has been given to the nurse for review.
- Unit Managers, or designee, will be responsible for taking any therapy referral orders for new admissions to the therapy department on the day of admission.
- DON and ADON provided education to all facility Licensed Nurses and Nurse Aides on new procedures for handling outside appointment paperwork and therapy referrals.
- Current facility Licensed Nurses and newly hired nurses not received education will not be allowed to work until the education has been completed.
- DON will utilize an active employee list to track completion of education and validate the post education written test was completed and passed.
- Education will also be included during orientation for newly hired facility Licensed Nurses, Nurse Aides, and Transportation drivers, to be completed by Director of Nursing or Nurse Manager.
- Administrator and Director of Nursing will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged noncompliance.
Failure to Assess and Communicate Post-Surgical Site Care Leading to Pressure Injury
Penalty
Summary
A resident with severe cognitive impairment, non-traumatic brain dysfunction, hypertension, and Alzheimer's disease experienced an unwitnessed fall resulting in a right elbow fracture. Following an open reduction internal fixation (ORIF) surgical procedure, the resident returned to the facility with specific post-operative instructions, including non-weight bearing status, pain management, and incision care. The discharge instructions also required follow-up with an orthopedic specialist and outlined care for the surgical site, including keeping the splint dry and monitoring for drainage. Despite these instructions, there were no documented nursing assessments of the surgical site from the time of surgery through the next scheduled follow-up appointment. At a follow-up appointment with the orthopedic surgeon, new orders were given for occupational therapy (OT) to address range of motion, pain, edema control, and splint management, including removal for hygiene and active ROM exercises. However, this order was not processed or communicated to the OT department, and the resident did not receive the prescribed therapy. Additionally, the facility failed to document any nursing assessments of the surgical site or the resident's condition related to the splint and wound care for an extended period. The resident's next follow-up appointment was delayed due to illness, and the facility did not seek further guidance from the orthopedic surgeon during this delay. When the resident was finally seen again by the orthopedic surgeon, the splint was removed, revealing a pressure wound over the medial aspect of the elbow, limited range of motion, and retained steri-strips from the previous visit. The wound was later identified as a medical device-related stage 4 pressure injury with exposed hardware, which continued to deteriorate and ultimately required emergent surgery for irrigation, debridement, and hardware removal. Throughout this period, there was a lack of documented assessments and communication regarding the resident's surgical site, therapy needs, and wound care, directly contributing to the development and worsening of the pressure injury.
Failure to Remove Expired Food and Maintain Food Storage Standards
Penalty
Summary
Surveyors observed that the facility failed to remove expired food items from storage areas and did not properly label or clean food storage bins. In the walk-in refrigerator, a sealed bag of pre-packaged chopped celery with a use by date that had passed was found on the second shelf. The Dietary Manager acknowledged that the celery should have been removed but had been overlooked. Additionally, in the dry food storage area, four loaves of bread were found with use by dates that had expired, and the Dietary Manager stated that she did not realize the bread needed to be dated when removed from the freezer. Further observations revealed that three large plastic storage bins containing flour, sugar, and rice were not labeled with open or use by dates. The bins' attached scoop holders contained food debris and other debris at the bottom, with the scoops directly touching the debris. The Dietary Manager stated that the bins and scoop holders were cleaned every 30 days when the contents expired, but she was unaware of the last time they had been cleaned. The Administrator confirmed that expired food should have been disposed of, bins should have been dated, and cleaning should have occurred as required.
Failure to Obtain Orders and Provide Timely Pressure Ulcer Care on Admission
Penalty
Summary
The facility failed to obtain physician orders and provide timely wound care treatment for two mid-spine pressure ulcers present on admission for one resident. Upon admission, the nurse responsible for the initial skin assessment did not document the presence of the spinal wounds, despite observing a dressing on the resident's spine. The nurse, who was new to the facility, was unsure about wound care standing orders and did not notify anyone to obtain wound care orders on the day of admission or the following day. As a result, no wound care orders were in place for the resident's spinal wounds for the first two days after admission. The resident, who had a history of joint replacement surgery and dementia, was identified as being at risk for skin breakdown and required significant assistance with activities of daily living. The wounds were only formally identified and addressed by the wound care nurse on the third day after admission, at which point wound care orders were initiated and treatment began. Documentation confirmed that wound care was not provided or recorded for the spinal wounds during the initial period after admission, and the physician was not notified in a timely manner regarding the need for wound care orders.
Medications Left Unsecured at Bedside Without Self-Administration Assessment
Penalty
Summary
Nursing staff failed to ensure that medications were properly secured and administered according to facility policy and professional standards. In two separate cases, nurses left medications at the bedside of residents who had not been assessed for self-administration. One resident, who was cognitively intact but had no documented assessment for self-administration, was observed with a medication cup containing multiple pills and a cup of water on his bedside table. The resident confirmed that the nurse routinely left his pills for him to take, and he self-administered the medication during the observation. The assigned nurse initially believed the resident was assessed for self-administration but later admitted she had not witnessed the resident take the medication and acknowledged she should have stayed to observe ingestion. In another instance, a cognitively intact resident was found with a medication cup containing five pills and another cup with liquid medication on his bedside table. The resident reported that a nurse had given him the medications and was impatient, repeatedly urging him to take them. Medication administration records did not show that this nurse had administered medications to the resident in the past 30 days. Further review indicated that the resident's scheduled medications matched the pills found at the bedside, and interviews with multiple nurses revealed confusion about who had left the medications. None of the nurses involved could confirm that the resident had been assessed for self-administration, and the medical director confirmed that such an assessment had not been completed. Both the Director of Nursing and the Administrator stated that facility policy requires nurses to observe residents taking their medications unless a formal assessment for self-administration has been completed. In both cases, medications were left at the bedside without such assessments, and the responsible staff could not provide a clear explanation for this deviation from protocol.
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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 Asheville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elevate Health And Rehabilitation | 0.8 mi | ★★★★★ | 1 | 0 |
| The Laurels Of Greentree Ridge | 1.4 mi | ★★★★★ | 0 | 0 |
| Aston Park Health Care Center | 2.2 mi | ★★★★★ | 10 | 0 |
| River Bend Health And Rehabilitation | 3.6 mi | ★★★★★ | 4 | 0 |
| Deerfield Episcopal Retirement | 4.2 mi | ★★★★★ | 1 | 0 |
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