Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Stonecreek Health And Rehabilitation during CMS and state inspections, most recent first.
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.
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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Illustrative
What surveyors actually found near you
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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 | ★★★★★ | 4 | 1 |
| The Laurels Of Greentree Ridge | 1.4 mi | ★★★★★ | 0 | 0 |
| Aston Park Health Care Center | 2.2 mi | ★★★★★ | 2 | 0 |
| River Bend Health And Rehabilitation | 3.6 mi | ★★★★★ | 4 | 0 |
| Deerfield Episcopal Retirement | 4.2 mi | ★★★★★ | 1 | 0 |
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