Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265582

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

STONECREST HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

2 HIGHWAY Y, PO BOX 707
VIBURNUM, MO 65566

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide timely notification to the resident, and if applicable to the resident
representative and ombudsman, before transfer or discharge, including appeal rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to notify the resident and/or
the resident’s representative in writing of a transfer or discharge to a hospital,
including the reasons for the transfer for three residents (Resident #1, #45, and #56) of
three sampled residents transferred to the hospital. The facility census was 59.
1. Record review of Resident #1’s medical record, showed:
– The resident transferred to the hospital on [DATE] and returned to the facility on
[DATE];
– No documentation of a letter notifying the resident and/or the resident’s representative
of the resident’s transfer to the hospital and the reason for the transfer.
2. Record review of Resident #45’s medical record, showed:
– The resident transferred to the hospital on [DATE] and returned to the facility on
[DATE];
– The resident transferred to the hospital on [DATE] and returned to the facility on
[DATE];
– The resident transferred to the hospital on [DATE] and returned to the facility on
[DATE];
– No documentation of a letter notifying the resident and/or the resident’s representative
of the resident’s transfer to the hospital and the reason for the transfer on 9/5/18,
9/21/18, and 9/30/18.
3. Record review of Resident #56’s medical record, showed:
– The resident transferred to the hospital on [DATE] and returned to the facility on
[DATE];
– No documentation of a letter notifying the resident and/or the resident’s representative
of the resident’s transfer to the hospital and the reason for the transfer.
During an interview on 10/25/18 at 9:30 A.M., the Administrator said the facility has not
been providing any notices unless it was a 30 day emergency discharge.
Record review of the facility’s Resident Transfer to Hospital/Health Care Facility policy,
dated (MONTH) (YEAR), showed the facility’s Social Services Director/designee will notify
the resident’s family or legal guardian, regarding reason, and location of discharge.

F 0625

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Notify the resident or the resident’s representative in writing how long the nursing
home will hold the resident’s bed in cases of transfer to a hospital or therapeutic
leave.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview, and record review, the facility failed to inform the resident and
family or legal representative of their bed hold policy at the time of transfer to the
hospital for three residents (Resident #1, #45, and #56) of three sampled residents. The
facility census was 59.
1. Record review of Resident #1’s nurse’s notes showed:
– The resident transferred to the hospital on [DATE] and readmitted to the facility on
[DATE].
Review of the resident’s record showed no documentation the resident or family member was
informed in writing of the facility bed hold policy at the time of transfer on 10/6/18.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265582

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

STONECREST HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

2 HIGHWAY Y, PO BOX 707
VIBURNUM, MO 65566

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0625

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
2. Record review of Resident #45’s nurse’s notes showed:
– The resident transferred to the hospital on [DATE] and readmitted to the facility on
[DATE];
– The resident transferred to the hospital on [DATE] and readmitted to the facility on
[DATE];
– The resident transferred to the hospital on [DATE] and readmitted to the facility on
[DATE].
Review of the resident’s record showed no documentation the resident or family member was
informed in writing of the facility bed hold policy at the time of transfer on 9/5/18,
9/21/18 or 9/30/18.
3. Record review of Resident #56’s nurse’s notes showed:
– The resident transferred to the hospital on [DATE] and readmitted to the facility on
[DATE].
Review of the resident’s record showed no documentation the resident or family member was
informed in writing of the facility bed hold policy at the time of transfer on 8/27/18.
During an interview on 10/25/18 at 9:30 A.M., the Administrator said the facility had not
been doing any of the notices unless it was a 30 day emergency discharge.
Record review of the facility’s Bed Hold policy, dated (MONTH) (YEAR), showed:
– The resident receives a copy of the bed hold policy upon admission;
– The resident or their legal representative receives a copy bed hold policy upon
discharge to the hospital or going on therapeutic leave.

F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Develop the complete care plan within 7 days of the comprehensive assessment; and
prepared, reviewed, and revised by a team of health professionals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review the facility failed to update and revise care plans
with specific interventions tailored to meet individual needs for three residents
(Resident #6, #45, and #56) out of 18 sampled residents. The facility census was 59.
1. Record review of Resident #6’s physician’s orders [REDACTED].
– an order for [REDACTED].>- An order, for [MEDICATION NAME] 5/325 (pain medication) mg
two tablets by mouth every four hours as needed for a pain scale greater than six (with a
pain scale 0-10, 0 being no Pain and 10 being worse pain possible).
Record review of the residents quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument required to be completed by facility staff, dated 7/23/18 showed:
– Received a scheduled pain medication;
– Assessed for frequent pain.
Record review of the residents care plan, updated 7/26/18 showed:
– Pain not care planned.
During an interview on 10/26/18 at 9:05 A.M. the Director of Nursing (DON) said pain
should be addressed on the care plan.
2. Record review of Resident #45’s medical chart showed:
– The resident was readmitted to the facility on [DATE] with an indwelling catheter (a
flexible tube inserted into the bladder to drain and collect urine);
– A [DIAGNOSES REDACTED].
Record review of care plan revised 10/15/18, showed:
– Foley catheter in place since readmission due to enlarged prostate;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265582

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

STONECREST HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

2 HIGHWAY Y, PO BOX 707
VIBURNUM, MO 65566

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 2)
– Change monthly;
– Interventions for catheter care not addressed.
3. Record review of Resident #56’s medical chart showed:
– [DIAGNOSES REDACTED].
– Re-admitted on [DATE] with an indwelling catheter.
Record review of the resident’s quarterly MDS, dated [DATE] showed:
– Indwelling catheter.
Record review of the resident’s care plan, updated 9/7/18 showed:
– No care plan for the catheter or care of the catheter.
During an interview on 10/25/18 at 2:38 P.M., Licensed Practical Nurse (LPN) A said the
catheter and daily catheter care should be addressed on the care plan.
Record review of the facility’s Comprehensive Care Plan, dated (MONTH) 6, (YEAR) showed:
– The purpose of this policy is to ensure the facility must develop a comprehensive care
plan for each resident that includes measurable objectives and timetables to meet a
resident’s medical, nursing, and mental psychosocial needs that are identified in the
comprehensive assessments;
– Assessing and planning for care sufficient to meet the care needs of new admissions.

F 0661

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure necessary information is communicated to the resident, and receiving health care
provider at the time of a planned discharge.

Based on interview and closed record review, the facility failed to complete a
comprehensive discharge summary for one resident (Resident #61) of one sampled discharged
resident. The facility census was 59.
1. Record review of Resident #61’s closed medical record showed the resident discharged to
another facility on 8/23/18 and staff did not complete a comprehensive discharge summary.
During an interview on 10/25/18 at 3:35 P.M., the Administrator said:
– A discharge summary had not been completed on Resident #61.
During an interview on 10/26/18 at 10:30 A.M., the Director of Nursing (DON) said:
– A discharge summary had not been completed on Resident #61;
– She thought the resident was going to stay in the facility and did not know the resident
had plans on transferring to another facility.
Record review of the facility’s Policy and Procedure for Resident Transfer/Discharge,
Immediate Discharge, and Therapeutic Leave Policy with an effective date of (MONTH) 28,
(YEAR) showed the discharge summary to include the following information:
– Active medication orders;
– Active non-medication orders;
– Active Diagnosis;
– Plan of care;
– All contacts;
– All providers;
– Skin condition report.

F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate care for residents who are continent or incontinent of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265582

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

STONECREST HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

2 HIGHWAY Y, PO BOX 707
VIBURNUM, MO 65566

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract
infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review the facility failed to obtain an order
for [REDACTED].
1. Record review of Resident #45’s Physician order [REDACTED].
Record review of Resident #45’s medical chart showed:
– The resident was readmitted to the facility on [DATE] with an indwelling catheter;
– A [DIAGNOSES REDACTED].
– an order for [REDACTED].>- A PICC line (a long, thin tube that goes into your body
through a vein, the end of this catheter goes into a large vein near your heart to carry
nutrients and medicines into your body), for [MEDICATION NAME].
Observations of Resident #45, showed:
– On 10/24/18 at 8:47 A.M., the resident sat in his/her wheelchair on the 100 hall with
catheter bag hanging under the wheelchair in a white pillowcase dragging the floor;
– On 10/24/18 at 12:31 P.M., the resident sat in his/her wheelchair in the main dining
area with catheter bag hanging under the wheelchair in a white pillowcase dragging the
floor;
– On 10/24/18 at 2:24 P.M., the resident sat in his/her wheelchair in the front hall area
with catheter bag hanging under the wheelchair in a white pillowcase dragging the floor;
– On 10/25/18 at 1:35 P.M. the resident sat in his/her wheelchair on the 100 hall with
catheter bag hanging under the wheelchair in a white pillowcase dragging the floor;
– On 10/26/18 at 9:15 A.M., the resident sat in his/her wheel chair in front hall,
catheter in white pillowcase, hanging from mid back of wheel chair above the area of the
bladder, causing the urine to flow backward.
During an interview on 10/25/18 at 2:38 P.M., Licensed Practical Nurse (LPN) A said the
resident was readmitted from the hospital on [DATE] with the catheter due to enlarged
prostate, The POS should have an order for [REDACTED].>During interviews on 10/25/18 at
3:13 P.M., and 10/26/18 at 9:30 A.M., the Director of Nursing (DON) said there should be
an order for [REDACTED]. in a pillow case but they are out of privacy bags.
Record review of the facility’s policy’s for Urinary Catheter Care, not dated, showed:
– Residents who have a urinary catheter will have a physician’s orders [REDACTED].
– Residents with catheters will receive catheter care every shift or as ordered by the
physician;
– Keep the drainage bag below the level of the bladder to prevent backflow of the urine;
– Make sure the drainage bag does not drag and does not touch the floor.

F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure drugs and biologicals used in the facility are labeled in accordance with
currently accepted professional principles; and all drugs and biologicals must be stored
in locked compartments, separately locked, compartments for controlled drugs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review the facility failed to label and store
medications in a safe and effective manner. The facility census was 59.
1. Observation on 10/26/18 at 9:25 A.M. of the medication room refrigerator, showed:
– An opened multi-use vial of [MEDICATION NAME] (anti-anxiety medication), undated;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265582

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

STONECREST HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

2 HIGHWAY Y, PO BOX 707
VIBURNUM, MO 65566

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
– An opened multi-use vial of [MEDICATION NAME] Purified Protein Derivative (TPPD),
undated;
– Two opened bottles of [MEDICATION NAME] (used to lower levels of sugar in the blood),
undated;
– Three opened bottles of [MEDICATION NAME] (used to lower levels of sugar in the blood),
undated;
– An opened bottle of Humalog (used to lower levels of sugar in the blood), undated;
– An opened multi-use bottle of [MEDICATION NAME] R (used to lower levels of sugar in the
blood).
Review of the manufacturer’s recommendations for TPPD showed the medication to be
discarded 30 days after it is opened.
Review of the manufacturer’s recommendations for [MEDICATION NAME] and Humalog showed the
medications to be discarded 28 days after it is opened.
Review of the manufacturer’s recommendations for [MEDICATION NAME] and [MEDICATION NAME]
showed the medications to be discarded 42 days after it is opened.
During an interview on 10/26/18 at 9:42 A.M. the Certified Medication Technician (CMT) B
said, the nursing staff give the injections and it is the nurse’s responsibility to date
the bottle when they are opened.
During an interview on 10/26/18 at 10:00 A.M. the Director of Nursing (DON) said the
multi-dose vials should be dated when opened and she would take care of all of the open
undated mediations.
The facility did not provide a policy on multi-dose medication.