Stone Pear Pavilion
Inspection history, citations, penalties and survey trends for this long-term care facility in Chester, West Virginia.
- Location
- 125 Fox Lane, Chester, West Virginia 26034
- CMS Provider Number
- 515130
- Inspections on file
- 15
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Stone Pear Pavilion during CMS and state inspections, most recent first.
Kitchen Staff Lacked Required Food Handler Credentials: During interview and record review, three dietary employees were found to be working without food handler cards after 30 days of employment, contrary to Virginia code 16-2-16. Their job descriptions showed they were responsible for meal prep and service tasks, including assisting the cook, preparing foods and beverages, and obtaining food safety certification.
Food temperatures were not properly monitored before meals were served. The facility was not following state, federal, or its own policy for checking and recording temperatures on all food items, and the temperature logs for the month were not documented until the DON filled them in. The kitchen’s log only covered a few food categories and did not include other items, including mechanically altered foods. Residents reported that the food was not hot, and one resident said the food was cold and bad.
Food storage, sanitation, and dish machine temperature standards were not followed. Surveyors observed soiled kitchen equipment and surfaces, ice in the handwashing sink, employee beverages in food prep areas, and many food items that were unlabeled, undated, improperly stored, or expired. The dish machine repeatedly registered below the required temperature, and staff reported missing or unused temp logs.
Improper storage and disposal of garbage and refuse was observed when the kitchen trash can lid was not secured on two separate observations and both sliding doors on the dumpster were left open. An employee acknowledged the trash can lid should be secured when not in constant use and stated the doors needed to be closed.
Uneven Meal Service During Dining: The facility failed to ensure dignity during meals when roommates and tablemates were not served at the same time. A resident in a shared room received a tray well before the roommate, and another roommate pair had a similar delay. In the dining room, five residents ordered together but were served over an 11-minute span, with staff stating trays were delivered based on when orders were taken and received by the kitchen.
A resident’s care plan was not updated to reflect her role as Resident Council President, and another resident’s fall interventions were not followed as written. Staff observed the fall mat on the wrong side of the bed, no "Call don't fall" sign in the room, and an LPN confirmed the ordered setup was not in place; the same LPN also confirmed the resident was not wearing hip protectors.
The facility failed to provide an activity program that matched resident interests and functional abilities. Multiple residents reported too few meaningful evening activities, with bingo shortened and evening programming limited mainly to reading groups, while the activity calendar also listed a hydration cart as an activity. A resident with severe cognitive impairment was observed crying out, agitated, or asleep in the activity room without staff engagement, and the AD stated sensory stimulation activities were not offered because residents refused them, though no documentation supported that claim.
A resident with a history of falls, confusion, and poor memory had repeated falls documented in the chart. The care plan called for bilateral hip protectors in bed, a visible "Call don't fall" sign, and a fall mat on the right side of the bed, but observation found the mat on the left side, no sign in the room, and an LPN confirmed the resident was not wearing hip protectors.
The facility failed to ensure daily nurse staffing postings were accurate because the posted staffing information did not include total hours worked. An observation showed the posting was missing this required information, and record review of postings over the past year found the same omission on all postings reviewed. The DON confirmed the postings did not contain the required information.
Medication Error Rate Exceeded Threshold: An LPN administered the wrong meds from a pill packet to a resident, giving mirtazapine at the wrong time and omitting two ordered morning antihypertensives. The facility’s medication error rate was 12% based on 3 errors in 25 opportunities.
Infection control practices were not followed during medication administration and meal service. An RN picked up a dropped Zoloft pill with a bare hand and did not perform hand hygiene before or after giving medication to a resident, and dietary staff did not clean their hands between tray deliveries or offer residents hand hygiene before meals. The DON confirmed the medication pass and hand hygiene practices were not completed as expected.
Failure to notify the physician of a resident’s bleeding. Nursing notes documented dark red vaginal discharge, then vaginal blood and blood in the urine after bed pan use, with an RN noting dried blood on the thighs and vagina and that the NP would evaluate the resident on rounds. The resident said she wanted to see the physician about the bleeding but believed the physician had already left, and the DON confirmed the physician had not evaluated the resident and there was no documentation that the physician had been notified of the earlier bleeding.
An opened multi-use vial of Aplisol was found in the med room refrigerator after being in use longer than the FDA-labeled 30-day limit. An LPN confirmed the vial was out of date and noted the package insert was no longer with it.
Menus were not followed and meal items were randomly substituted. A resident who reported being diabetic said the food was cold and bad, had not seen a dietitian, and found that her tray ticket did not match the menu copy in her room; she also did not receive the soup listed on her ticket. At a resident council meeting, residents said they did not get what was on their tray tickets, did not know the soup of the day, and were missing items from their trays.
The facility failed to maintain a safe and sanitary environment in the east and west shower rooms. A resident reported mold on the floor and walls of the east shower room, which was confirmed by an observation revealing a black substance and debris on the vents. The Environmental Services Supervisor acknowledged the need for cleaning, citing moisture challenges. Similarly, the [NAME] wing shower room had a black substance between tiles and debris on vent grills, with the supervisor confirming the need for cleaning.
The facility failed to notify a physician when a resident's blood sugar levels exceeded 400 on multiple occasions, as required by the physician's order. Additionally, there was a discrepancy in the code status documentation for another resident, with the electronic medical record not reflecting the updated POST form indicating Full Code / Full Treatment.
The facility did not maintain the required RN coverage of eight consecutive hours daily, as evidenced by ten instances of insufficient coverage. This included several days with only six to seven hours of RN presence and one day with no RN coverage, potentially impacting all 58 residents.
The facility was found to have sanitation deficiencies in the kitchen, including a mobile utility cart with old food and debris on its shelves, and debris under prep tables and the stove. The Dietary Manager confirmed these issues during a survey and was previously unaware of them.
The facility did not support resident choice, as two residents' requests were ignored. One resident wanted three showers a week but was only scheduled for two, and another resident, who is Catholic, wanted assistance by 7:00 AM for religious activities, but her requests were not met. Staff acknowledged the challenges but did not fulfill the residents' preferences.
A resident's grievance about her roommate's husband's late-night visits was not addressed by the facility, despite the grievance policy requiring prompt action. The Social Worker did not document the complaint, and the Resident Council reported that grievances were generally not resolved, highlighting a deficiency in the facility's grievance handling process.
A facility failed to accurately complete an MDS assessment for a resident, as it did not reflect the use of bilateral hearing amplifiers. The resident, who is hard of hearing, reported dependency on these amplifiers, which were confirmed by the Social Worker to have been in use since May. However, the MDS incorrectly indicated 'No' for the use of hearing appliances, which was acknowledged by the MDS LPN as needing correction.
A facility failed to ensure a resident's PASARR accurately reflected their diagnosis of Major Depressive Disorder. The PASARR did not identify the disorder, indicating no Level II screening was needed, and a new PAS was not completed to assess the need for specialized services. The Social Worker acknowledged the error and noted ongoing efforts to review PASRRs for accuracy.
The facility did not ensure a safe environment by leaving two bathrooms near the physical therapy room and lounge unlocked and accessible to residents, without nurse call devices or emergency pull alarms. The administrator admitted these bathrooms were not meant for resident use but could not explain how residents were prevented from accessing them.
A resident's toileting needs were not met according to a physician's order, leading to accidents. The resident was supposed to be toileted multiple times a day, but records showed this occurred only twice daily. This failure was confirmed by the MDS Coordinator.
A resident with a fractured ankle experienced inadequate pain management, reporting pain levels as high as ten out of ten. Despite consistent high pain ratings, the resident was only given Acetaminophen 650 MG, which did not sufficiently alleviate her discomfort. The LPN acknowledged the resident's pain but did not take further action, and the physician was not notified until prompted by a surveyor.
The facility did not ensure the Medical Director or designee attended the QAA meetings quarterly, as required. A review of sign-in sheets from August 2023 to August 2024 revealed no attendance by the Medical Director for the quarter from January to March 2024. The DON also found no evidence of the Medical Director's presence in the January 2024 meeting minutes. This oversight could potentially affect more than a limited number of residents, with a facility census of 58.
Kitchen Staff Lacked Required Food Handler Credentials
Penalty
Summary
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service was not met when the facility failed to employ kitchen staff with the appropriate credentials. During interview and record review, dietary employees #28, #56, and #78 were found to not have their food handler cards after 30 days of employment, as required by Virginia code 16-2-16. The facility census was 56 at the time of the survey. Employee #100 provided the surveyor with the job description for the three kitchen employees who did not have food handler cards at the beginning of the survey process. The job description stated that these employees assist in meal preparation and service, including setting up and covering desserts, pouring and covering beverages, attending and stirring foods during cooking to prevent burning, relieving the cook of duties such as preparing fruits and vegetables and making toast and beverages, and completing annual state-mandated training requirements. It also stated that they are required to obtain food safety certification and have skills specific to preparing meals for geriatric residents.
Food Temperatures Not Properly Monitored Before Service
Penalty
Summary
The facility failed to ensure food and drink were palatable, attractive, and served at safe and appetizing temperatures. During record review, the surveyor found that the facility was not following state or federal guidelines, or its own policy, for taking and recording temperatures on all food items prepared in the dietary department before serving residents. The policy stated that no food would be served unless it met food code standard temperatures, but the facility did not know whether temperatures met those standards because all required temperatures were not being taken. On 03/02/2026 at 11:40 AM, the surveyor requested the food temperature logs and found none documented for March 2026; the Director of Dining then filled them in. The logs only had five sections for starch, protein, dessert, drink, and vegetable, and the kitchen did not take or record temperatures for any other food items prepared and sent to residents, including mechanically altered foods. During Resident Council on 03/03/2026 at 1:00 PM, residents stated the food was not hot, and Resident #51 stated the food was cold and bad.
Food Storage, Sanitation, and Dish Machine Temperature Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety, and failed to follow proper sanitation practices for the kitchen and food preparation equipment. During an initial walkthrough of the kitchen, the Director of Dining acknowledged multiple sanitation and storage issues, including soiled fan guard covers in the walk-in refrigerator, dusty ice machine air filter covers, a soiled can opener, an oven rack sitting directly on the floor, heavily soiled ovens, a soiled shelf below the flat top, a soiled shelf under the soda dispenser, crumb buildup in both toasters, and no posted kitchen or equipment cleaning schedule. The surveyor also observed multiple food items that were not dated, labeled, sealed, or had expired use-by dates, including rolls, mozzarella cheese, beverages, bacon bits, a bagged lunch, beef stew, cinnamon rolls, onion rings, beef briskets, croissants, hot dogs, cream cheese, spices, and a dented can of spaghetti sauce stored without a designated area. On the follow-up visit, additional food safety concerns were observed, including employee beverages beside the microwave and on a cart in the kitchen, a soiled can opener base, ice in the hand washing sink, and grease and debris on the wall and floor behind the ovens, the stove drip pan, and both ovens. Numerous items in the sandwich cooler, reach-in refrigerator, and nourishment room were not labeled or dated, including sandwiches, coleslaw, diced vegetables, fruit salad, applesauce, an unknown beverage, crushed pineapple, soups, puddings, salad dressings, condiments, ham salad, olives, tartar sauce, unknown food, boiled eggs, pancake batter, liquid eggs, yogurt, and hot [NAME] mix with outdated use-by dates. The dish machine temperature was repeatedly below the required minimum of 120 degrees F, and staff reported that dish machine temperature logs were not being used consistently and that six months of logs had been discarded.
Improper Storage and Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to store and dispose of garbage and refuse properly. During survey observations, the dumpster had both sliding doors open, and the lid on the trash can located in the kitchen was not secured on two separate observations. On 03/02/2026 at 12:11 PM, Employee #100 acknowledged that the kitchen trash can lid should be secured when not in constant use. The same issue was observed again on 03/03/2026 at 12:35 PM, and the dumpster doors were observed open on 03/03/2026 at 12:55 PM. Employee #100 stated, "we got to start closing the doors."
Uneven Meal Service During Dining
Penalty
Summary
The facility failed to ensure resident dignity during dining by not serving roommates and tablemates at the same time. During the resident council meeting, residents reported that roommates did not receive their meal trays at the same time when they dined in their rooms. On observation, Resident #27 received a dinner tray at 4:46 PM while the roommate, Resident #55, did not receive a tray until 5:01 PM, and Resident #55 was seen asking a staff member where her tray was after Resident #27 had already been served. Resident #15 received a dinner tray at 4:55 PM, while the roommate, Resident #54, did not receive a tray until 5:27 PM. In the dining room, five residents were observed sitting at the table and placing their dinner orders at the same time, but they were served at different times. Resident #40 received dinner at 4:15 PM, Resident #31 at 4:20 PM, Resident #50 at 4:21 PM, Resident #13 at 4:22 PM, and Resident #43 at 4:26 PM, with 11 minutes between the first and last resident served. Dietary Worker #62 stated that trays were delivered based on when meal orders were obtained by Nurse Aides and then filled and delivered in the order received by the kitchen. The Administrator stated the facility used an open dining policy and that meal orders were taken by Nurse Aides using computer tablets, with meals served according to when the orders were taken, which led to different meal service times for roommates dining in their rooms.
Care Plan Not Updated and Fall Interventions Not Followed
Penalty
Summary
Failure to develop and implement complete care plans was identified for two residents. Resident #2 stated during interview that she was the Resident Council President and expressed concern that there were not enough evening activities, noting that she held a weekly reading group at 6:00 PM and that some residents would enjoy evening crafting and Bingo. However, the care plan still listed her as serving as Resident Council President as of February 2022, and the Activity Director stated she believed the care plan had been changed but, when shown the document, said, "I don't understand; I thought I changed it." This confirmed the care plan was not updated to reflect her role as Resident Council President. Resident #10 had fall interventions listed on the person-centered care plan, including bilateral hip protectors when in bed, a "Call don't fall" sign in the room within view, and a fall mat to the right side of the bed due to a history of falling. During observation, the fall mat was placed on the left side of the bed, there was no "Call don't fall" sign hanging in the room, and an LPN confirmed the mat should have been on the right side of the bed and that the sign was not present. The same LPN also checked Resident #2 and confirmed she was not wearing hip protectors.
Activity Program Did Not Meet Resident Needs
Penalty
Summary
The facility failed to ensure its activity program met residents’ interests and psychosocial needs by providing insufficient evening activities, listing a hydration cart as an activity on the calendar, and not providing sensory stimulation programming for lower-functioning residents. Review of the activity program, resident council concerns, resident interviews, and activity calendars for January through March 2026 showed that multiple residents reported a lack of meaningful evening activities, including limited bingo time, no shopping trips since October, and evening programming that was mainly a resident-led reading group. Residents also stated these concerns had been brought to staff previously without follow-through. The activity calendars listed a hydration cart daily at 1:00 PM as an activity. During interview, the Activities Director stated, “They told me I had to put that on there,” confirming the hydration cart itself was not an activity. The report states that providing hydration is a clinical service intended to meet residents’ nutritional and hydration needs and does not constitute a recreational or interest-based activity. Resident #10, who had a BIMS score of 99 and was documented as having no cognitive capacity, was observed multiple times in the activity room crying out, appearing agitated, or asleep without staff interaction. The resident’s activity care plan identified interests such as movies, puzzles, crossword and word search puzzles, and country and gospel music, and included encouragement to participate in activities and independent activities. The Activities Director stated sensory stimulation activities were not offered because residents refused them, but could not explain how low-functioning residents who could not communicate would refuse such activities, and no documentation was found supporting the statement that the resident’s daughter did not want sensory activities.
Failure to Follow Fall Safety Interventions
Penalty
Summary
The facility failed to provide an environment free from accident hazards by not following the resident’s fall interventions as documented in the person-centered care plan. Record review showed the resident had multiple falls, including falls on 11/18/25, 12/25/25, 12/31/25, 1/14/26, and 2/6/26. The care plan included bilateral hip protectors when in bed, a "Call don't fall" sign in the room within view, and a fall mat to the right side of the bed due to a history of falling, confusion, and poor memory. During observation, the fall mat was placed on the left side of the bed and there was no "Call don't fall" sign hanging in the room. An LPN confirmed the fall mat should have been on the right side of the bed and that the sign was not present; the LPN also confirmed the resident was not wearing hip protectors.
Incomplete Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure the posted daily nurse staffing information was accurate because the staff postings did not include total hours worked. During an observation on 03/02/26 at 12:04 PM, the staff posting was seen without the total hours worked posted. Record review on 03/02/26 for staff postings over the past year showed that none of the postings contained total hours worked. During an interview on 03/02/26 at 1:04 PM, the DON was asked what was missing from the posting and, after being informed of the staffing posting requirement, stated, "Ok, i will get working on fixing this now," confirming the postings did not contain the required information. The facility census was 56.
Medication Error Rate Exceeded Threshold
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent, with three medication errors identified during 25 medication opportunities for an error rate of 12%. For Resident #9, an LPN administered ferrous sulfate 325 mg, mirtazapine 15 mg, and rivastigmine tartrate 1.5 mg from a pill packet containing all three medications. Review of the physician’s orders showed the resident’s morning medications were losartan potassium 50 mg and metoprolol tartrate 25 mg for hypertension, ferrous sulfate 325 mg twice daily for anemia, and rivastigmine tartrate 1.5 mg twice daily for dementia, while mirtazapine 15 mg was ordered at bedtime for depression and poor appetite. When questioned, the LPN confirmed she had given mirtazapine at the wrong time because it was ordered for bedtime and had omitted losartan potassium and metoprolol tartrate, which were scheduled for the morning.
Infection Control Lapses During Medication Pass and Meal Service
Penalty
Summary
The facility failed to ensure proper infection control practices were completed during medication administration and during hand hygiene opportunities on the resident halls. On 03/04/26 at 9:39 AM, RN #26 was observed preparing medication for Resident #3 and dropped a Zoloft pill directly onto the medication cart, which had no barrier. RN #26 picked up the pill with a bare hand and did not perform hand hygiene before or after administering the medication. At 10:00 AM, the DON confirmed the pill should not have been picked up with a bare hand, a barrier should have been used on the medication cart, and hand hygiene should have been completed before and after medication administration. The facility's Hand Hygiene policy, dated 01/28/26, stated hand hygiene would be performed between resident contacts. On 03/03/26 at 4:42 PM, Dietary Worker #62 was observed delivering meal trays to residents in their rooms and touching overbed tables and items on the tables for Residents #47, #27, #22, and #38 without performing hand hygiene between tray passes. Later that evening, Dietary Worker #62 and NA #87 were observed delivering meal trays to residents dining in their rooms on [NAME] Hallway, and residents were not offered hand hygiene before the meal. Dietary Worker #62 stated he did not use hand hygiene between tray passes, and NA #87 acknowledged resident hand hygiene had not been performed before the meal, noting that hand wipes were available but had not been used.
Failure to Notify Physician of Resident Bleeding
Penalty
Summary
The facility failed to ensure the physician was notified when Resident #2 experienced a change in condition involving bleeding. On 02/28/2026, nursing documentation noted a small amount of dark red discharge from the vaginal area during morning care. On 03/02/2026, a CNA reported vaginal blood when placing the resident on the bed pan, and an RN assessed the resident and documented dried blood on the thighs and vagina, blood in the resident’s urine after getting off the bed pan, and that the nurse practitioner would evaluate the resident on rounds that morning; the resident was afebrile. During interview on 03/02/2026, the resident stated she wanted to see the physician that day regarding bleeding but thought the physician had already left without seeing her, and she was unsure whether the bleeding was vaginal or urinary. On 03/04/2026, the DON confirmed the physician had not evaluated the resident for bleeding on 03/02/2026 and that there was no documentation the physician had been notified of the bleeding on 02/28/2026.
Outdated Aplisol Vial Stored in Medication Refrigerator
Penalty
Summary
The facility failed to store medications in accordance with accepted standards of care when an opened multi-use vial of Aplisol, located in the medication room refrigerator, was found to have been opened more than 30 days earlier. During inspection of the medication preparation room with an LPN present, surveyors observed the vial with an opening date of 01/23/26, and the medication package insert was no longer with the vial. The FDA packaging insert for Aplisol states that vials in use for more than 30 days should be discarded. The LPN confirmed that the vial was out of date because it had been opened on 01/23/26.
Menus Not Followed and Meal Items Substituted
Penalty
Summary
The facility failed to meet residents’ nutritional needs in accordance with established national guidelines by not following the approved menus and making random substitutions of food items. On 03/03/2026, Resident #51 stated that the food was cold and bad, reported being diabetic and needing a diabetic diet, and said she had never seen a dietitian since being at the facility. She also compared her tray ticket with the menu copy kept in her room and said they did not match, noting that she did not receive the corn chowder listed on her tray ticket and instead received vegetable soup. At the resident council meeting on 03/03/2026, residents stated that menus were not followed, they did not receive what was on their tray tickets, they never knew what the soup of the day would be, they did not get served together, and items were missing from their trays. The report also states that on 03/03/2026 the lunch menu listed corn chowder, ham salad sandwich, and creamy cucumber salad, but the facility served vegetable soup, ham salad sandwich, and tater tots instead. Resident #35 and the resident council were identified as affected by the issue.
Failure to Maintain Sanitary Shower Rooms
Penalty
Summary
The facility failed to provide a safe, sanitary, and homelike environment in the east and west shower rooms, as observed during a survey. A resident reported that the east shower room had mold on the floor and walls, making her uncomfortable to use the facility due to inadequate cleaning. An observation confirmed the presence of a black substance on the floor and walls, along with a thick layer of lint and debris on the ceiling vents. The Environmental Services Supervisor acknowledged the need for cleaning, citing challenges in maintaining cleanliness due to moisture, and mentioned that power washing is done monthly. Similarly, an inspection of the [NAME] wing shower room revealed a black substance between the tiles and a thick, furry layer of lint and debris on the air conditioning vent grills. The Environmental Services Supervisor confirmed the dirty condition of the shower room walls and vents, despite efforts to power wash the walls. These findings indicate a failure to maintain a clean and safe environment in the shower rooms, as required by regulations.
Failure to Notify Physician of High Blood Sugar and Inconsistent Code Status Documentation
Penalty
Summary
The facility failed to provide care and services in accordance with acceptable standards of practice by not notifying the physician when a resident's blood sugar levels exceeded 400. Resident #56, who has Type II Diabetes Mellitus, had a physician order to call the doctor if blood sugar levels were above 400. However, a review of the Medication Administration Records from April to July 2024 revealed that the resident's blood sugar levels were over 400 on nine occasions without the physician being notified. This oversight was confirmed during an interview with the Director of Nursing, who stated that there was no evidence of physician notification for these instances. Additionally, the facility did not ensure consistency between the Physician Orders for Scope of Treatment (POST) form and the written physician orders on the chart for Resident #3. The electronic medical record listed the resident's code status as Full Code - Limited Additional Interventions, while the POST form, signed in March 2024, indicated Full Code / Full Treatment. The Director of Nursing acknowledged that the facility failed to update the resident's code status in the electronic medical record to reflect the POST form's instructions.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for eight consecutive hours a day, seven days a week, as required. A review of staffing schedules revealed ten instances where RN coverage was insufficient. On several occasions, RN coverage ranged from six to seven hours, and on one occasion, there was no RN coverage at all. This deficiency was identified during a review of staffing schedules and confirmed by the facility administrator, who was unable to provide evidence of adequate RN coverage on the specified dates. This lapse in RN coverage had the potential to affect all 58 residents at the facility.
Sanitation Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain cleanliness and sanitation standards in the kitchen, which had the potential to affect all residents receiving nutrition from this area. During an initial kitchen tour, surveyors observed a mobile utility cart with a toaster that had old food and debris on all three shelves. Additionally, there was old food and debris found under the prep tables, the stove, and another unspecified area. The Dietary Manager, when interviewed during the tour, confirmed the issues and stated she was unaware of them prior to the survey.
Failure to Support Resident Choice in Daily Activities
Penalty
Summary
The facility failed to honor the residents' rights to make choices about significant aspects of their lives, as evidenced by the experiences of two residents. One resident expressed a desire to have three showers a week, but the facility only scheduled her for two. Despite her repeated requests to the Nursing Assistants, her preference was not accommodated. The facility's staff, including a Nursing Assistant and an LPN, acknowledged the difficulty in meeting this request due to limited shower facilities and had informed the Clinical Operations Specialist of the resident's request. However, the resident's request remained unfulfilled at the time of the survey. Another resident, who is Catholic, wished to be assisted out of bed and cleaned by 7:00 AM to participate in her religious activities, including watching church services on TV and saying her rosary. She reported that her requests were ignored by the Nursing Assistant, and despite expressing her needs to a state representative, no changes were made. The nursing notes indicated that the resident was intermittently confused, which may have contributed to the staff's uncertainty about her needs. However, the resident was still able to communicate her preferences clearly.
Failure to Resolve Resident Grievance Promptly
Penalty
Summary
The facility failed to promptly resolve a grievance and keep the resident informed of the progress toward resolution, as required by their grievance policy. This deficiency was identified during the Long-Term Care Survey Process (LTCSP) for one of the three grievances reviewed. The facility's policy mandates immediate action upon receipt of a grievance to prevent further potential violations of residents' rights and requires the Grievance Committee to investigate and document the resolution of grievances. However, the facility did not adhere to these procedures in the case of a grievance raised by a resident. A resident expressed dissatisfaction with her living situation, specifically regarding her roommate's husband visiting late at night and staying for extended periods, which disturbed her rest. Despite raising this issue with the Social Worker, the grievance was not formally documented or addressed. The Social Worker perceived the resident's complaint as a desire to leave the facility rather than a grievance about the late-night disturbances. Additionally, the Resident Council reported that grievances were not being addressed or resolved, indicating a broader issue with the facility's grievance handling process.
Inaccurate MDS Assessment for Hearing Amplifiers
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for one of the residents reviewed during the Long-Term Care Survey process. Specifically, the MDS for Resident #36 did not accurately reflect that the resident had bilateral hearing amplifiers. During an interview, the resident reported being hard of hearing and dependent on these amplifiers, which were purchased with the help of the Social Worker. The Social Worker confirmed that the resident had been using the amplifiers since May 16, 2024. However, a review of the resident's Medicare - 5 Day MDS, with an Assessment Reference Date of June 23, 2024, showed that Section B, titled Hearing, Speech, and Vision, incorrectly answered 'No' to Question B0300 regarding the use of a hearing aid or other hearing appliance. An interview with the MDS LPN revealed acknowledgment of the incorrect coding and the need for modification to reflect the correct information.
Inaccurate PASARR for Resident with Major Depressive Disorder
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening and Resident Review (PASARR) for a resident accurately reflected their pre-admission diagnosis of Major Depressive Disorder. Upon review of the resident's records, it was found that the PASARR, dated 05/08/24, did not identify the resident's major depressive disorder in Section III, Question 30, and indicated that no Level II screening was required. This oversight meant that a new PAS was never completed to address whether specialized services were needed for the resident's condition. During an interview, the Social Worker acknowledged the error in the admitting PAS and noted that the facility had recently recognized the need to review new resident admission PASRRs for accuracy. The Social Worker was in the process of monitoring these reviews.
Inadequate Safety Measures in Facility Bathrooms
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards and did not implement adequate measures to reduce risks. During an observation, it was noted that two bathrooms near the physical therapy room and conference room/lounge were unlocked and accessible to both staff and residents at any time. These bathrooms lacked nurse call devices or emergency pull alarms, which are essential for resident safety. In an interview, the administrator acknowledged that these bathrooms were not intended for resident use but could not provide a reason preventing residents from accessing them. He mentioned that the bathrooms were equipped with grab bars and had passed previous surveys without issues being raised by surveyors.
Inadequate Toileting Care for Resident
Penalty
Summary
The facility failed to provide appropriate toileting care for a resident, leading to a deficiency in bowel and bladder care. The resident's sister reported that staff did not take her to the bathroom when needed, resulting in accidents. A physician's order required the resident to be toileted upon rising, before and after meals, and at bedtime, as well as when requested. However, documentation showed the resident was only toileted twice a day, which did not comply with the physician's order. This discrepancy was confirmed by the Minimum Data Set Coordinator during an interview.
Inadequate Pain Management for Resident with Fractured Ankle
Penalty
Summary
The facility failed to adequately assess and manage the pain of a resident who had fractured her right ankle and was experiencing significant discomfort. The resident, who had a cam walker boot applied after the removal of a cast, reported her pain level as ten out of ten during an interview. Despite this high level of pain, the resident was only administered Acetaminophen 650 MG as prescribed, which did not sufficiently alleviate her pain, as evidenced by her subsequent pain rating of five out of ten. The Licensed Practical Nurse (LPN) involved acknowledged the resident's high pain ratings but did not take further action to address the inadequacy of the pain management. The resident's care plan indicated an increased risk for pain due to her fractured ankle and diabetes mellitus, yet there was no specific physician's order addressing her current pain levels. The Clinical Operations Specialist stated that the resident's pain management was under the care of her Orthopedic Surgeon, with the next appointment scheduled over a month away. Despite the resident's consistent reports of pain, ranging from two to ten on a scale of ten over several weeks, the physician had not been notified, and no additional pain relief orders had been obtained until prompted by the surveyor.
Failure to Ensure Medical Director Attendance at QAA Meetings
Penalty
Summary
The facility failed to ensure that the required members attended the Quality Assessment and Assurance (QAA) meetings at least quarterly. Specifically, the Medical Director or their designee did not attend the QAA meetings for the quarter from January 2024 through March 2024. This was confirmed through a review of the sign-in sheets for QAA meetings from August 2023 through August 2024, which showed no signature from the Medical Director or designee for the specified quarter. Additionally, the Director of Nursing (DON) reviewed the minutes for the January 24, 2024, QAA meeting and found no evidence of the Medical Director's presence. This oversight had the potential to affect more than a limited number of residents, with the facility census being 58.
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The facility failed to prevent accident hazards and adequately supervise residents when two residents obtained cannabis gummies and CBD products via DoorDash, kept them in a bedside box with vape pens and OTC medications, and offered gummies to another resident, resulting in altered mental status, red eyes, paranoia, and ER transfers without a documented thorough investigation by administration. In a separate incident, a resident with decision-making capacity reportedly used a vape in a room with an active oxygen concentrator and refused a room search, leaving a potential fire hazard unresolved. Additional observations showed that a resident care planned for bilateral fall mats was in bed with one mat propped against the wall instead of on the floor, and another high-fall-risk resident was in bed with the bed not in the lowest position as required by the care plan, with staff confirming these fall-prevention interventions were not in place.
Two residents were not protected from neglect when one was left overnight in a soiled brief despite requests for incontinence care, resulting in raw, excoriated skin to the sacrum and scrotum, and another was served a grilled cheese sandwich despite an order for a mechanical soft diet, causing coughing before the tray was replaced. Staff interviews and documentation confirmed that the first resident had not been changed during the night and that prior skin assessments showed no issues, while the second resident’s diet order and the facility’s nutrition manual identified grilled sandwiches as inappropriate for a mechanical soft diet; neither incident was entered into the facility’s reportables or grievance systems.
The facility failed to accurately post daily nurse staffing information, with incorrect dates, unclear corrections, and mismatched total hours worked on most reviewed days. The daily staffing sheet was not readily visible on entry and, when located, contained multiple discrepancies between posted staffing and actual time-punch records. During one night shift, the posted sheet listed more LPNs and NAs than were actually present, with one NA found sleeping and another conducting personal business on a laptop in the breakroom, while one NA was assigned 1:1 to a resident, leaving two NAs to care for the remaining residents. These issues were confirmed through record review, observation, and staff interviews.
The facility failed to ensure adequate nursing staff on all shifts, leading to prolonged call light response times and unmet care needs. Multiple residents reported waiting from 45 minutes to several hours for assistance, including toileting and incontinence care, and described staff leaving the floor during smoke breaks and meal tray pass, leaving minimal coverage. Staffing records showed nursing HPPD below required minimums on at least one reviewed day, and an external report flagged low weekend staffing. One resident reported being left overnight in a soiled brief while having diarrhea, later found with raw, red skin to the sacral and scrotal areas, and this incident was not documented as a grievance or reportable event. A night-shift observation also revealed fewer staff on duty than posted, with one NA sleeping and another conducting personal business, while only two NAs were left to care for more than fifty residents.
Surveyors found that residents were not provided a way to file anonymous grievances and reported fear of retaliation for making complaints. During a Resident Council meeting, multiple residents stated they had no anonymous grievance option and felt their concerns raised in council were not taken seriously. The Social Worker confirmed there was no anonymous grievance mechanism and that residents and families had to request grievance forms from nursing or department heads, despite a written policy stating that residents and representatives have the right to file grievances orally or in writing and that staff will make prompt efforts to resolve them.
Two residents did not receive care according to physician orders and professional standards. One resident with a documented right hand contracture had orders and a care plan directing splinting of the left, functional hand, and surveyors observed the contracted right hand tightly fisted without a splint in place; the OT and DON later confirmed the order should have been for the right hand. Another resident with an order for Humalog Kwikpen requiring the provider to be called for blood sugar (BS) readings over 400 had multiple BS values above 400 documented on the MAR, but there was no documentation that the provider was notified on those occasions, which was confirmed by an RN consultant.
Surveyors identified multiple failures to follow food safety and sanitation policies, including soiled food service equipment, outdated and improperly labeled food items, and inadequate documentation of manual ware washing procedures. Personal items such as employee coats were stored on bread racks, and trash bins were placed on the same shelves as milk containers on beverage carts used for residents. These observations showed that staff did not consistently maintain clean food preparation areas, properly label and date TCS foods, or separate trash and personal belongings from food and food-contact surfaces.
The facility did not follow its own food safety and sanitation policies requiring trash to be contained in covered, leak-proof containers. During a kitchen walkthrough with the Director of Dining Services (DDS), a surveyor observed an uncovered trash can next to the juice machine and another uncovered trash can in the dish room. The DDS confirmed that these trash receptacles lacked lids, contrary to Healthcare Services Group (HCSG) policies that require the DDS to ensure appropriate lids are provided for all containers.
Two residents reported and staff observed sexually inappropriate behavior by a male resident, including entering a resident’s room uninvited while naked from the waist down and pulling on her in bed, and placing his hands under another resident’s blanket and rubbing near and on her private area. Both residents described the contact as unwanted, and one was documented as cognitively intact with capacity. Despite staff corroboration and resident statements to clinical providers, the facility’s investigations concluded that sexual abuse was not substantiated, citing lack of physical harm and inconsistent statements, and failed to adequately assess or address whether the residents felt safe or to alleviate their expressed anxiety.
The facility failed to ensure food was palatable, attractive, and maintained at a safe and appetizing temperature, as shown by tray temperature checks and interviews with several residents and staff. At lunchtime, kitchen staff were not taking or recording temperatures for items on the always-available menu, including beef patties, hotdogs, and brown gravy, before meal service began. The DDS acknowledged that temperatures for these always-available menu items were not being monitored or documented.
Failure to Control Resident Access to Non-Prescribed Substances and Implement Fall-Prevention Measures
Penalty
Summary
The facility failed to maintain an environment as free from accident hazards as possible and did not provide adequate supervision to prevent accidents, particularly related to resident access to non-prescribed substances and implementation of fall-prevention measures. An anonymous resident reported that two female residents purchased cannabis gummies via DoorDash and offered them to another resident, who refused. These two residents were later sent to the hospital after one was noticeably impaired. Record review showed no investigation documented in the facility’s reportable or grievance logs regarding these residents’ changes in condition due to cannabis gummies being brought into the facility and offered to other residents. Nursing documentation for one of the involved residents described a change in condition with altered mental status, suspicion of substance abuse, and tachycardia, leading to transfer to the ER for evaluation and toxicology screening. A late-entry note indicated the resident was educated on facility policies prohibiting OTC medications and CBD products in the room. Another nursing note detailed that a CNA reported a resident had consumed a gummy given by another resident, then discarded the second gummy, which the CNA retrieved from the trash. On assessment, the resident was found lying in bed with reddened eyes, reporting feeling tired, and vital signs were obtained. The resident stated she had consumed “pot gummies” and allowed the nurse to inspect a wooden box at the bedside, which contained several red sugar-coated gummies, three vape pens (including a suspected CBD vape pen), a bottle of Benadryl, and several Imodium tablets. The resident reported purchasing the gummies and CBD vape pen from DoorDash, and the items were removed with her consent. Further documentation showed that another nurse was informed that two residents had consumed an unknown gummy-like substance. On assessment, one resident had very red eyes and reported feeling paranoid, with vital signs recorded. This resident stated she had received two gummies from another resident and that a third resident knew about the gummies. The nurse interviewed the third resident, who reported that the resident supplying the gummies had told her she had gummies and THC pens and planned to give gummies to another resident. The nurse also noted that as staff were going to check on the resident who supplied the gummies, a DoorDash delivery person arrived and handed a bag to the nurse containing a pack of cigarettes and a receipt showing two CBD purchases. Facility administration had no evidence that a thorough investigation into this incident had been completed, and only limited action was taken following the event, leading surveyors to identify an immediate jeopardy situation due to residents being susceptible to drug abuse from other residents. The facility also failed to address other accident hazards and fall-prevention interventions for additional residents. One resident, who had capacity to make her own medical decisions, was involved in an incident where she reportedly used a vape in her room while an oxygen concentrator was present and turned on. The resident was verbally educated by the Administrator about the dangers of vaping near oxygen equipment, the smoking policy requiring smoking paraphernalia to be stored by nursing staff, and the prohibition of vaping inside the facility. However, during the survey period it remained unknown whether the resident still had vape pens in her possession, and she refused a room search, leaving a possible serious fire hazard unresolved at the time of review. In separate observations related to fall prevention, one resident was observed lying in bed with a fall mat that was supposed to be in place on the floor instead leaned against the wall behind the headboard. Record review confirmed the care plan required fall mats on both sides of the bed while the resident was in bed, and an LPN acknowledged that the floor mat was not in place. Another resident, care planned as at risk for falls due to multiple factors including muscle weakness, cognitive impairment, incontinence, psychoactive medication use, recent hospitalizations, visual impairment, and a history of traumatic brain injury and multiple CVAs, was observed lying in bed with the bed not in the low position despite a care plan intervention specifying that the bed should be in the lowest position. A RN consultant confirmed that the bed was not in the lowest position while the resident was in bed.
Failure to Prevent Neglect in Incontinence Care and Diet Texture Management
Penalty
Summary
The deficiency involves failure to protect residents from neglect by not providing timely incontinence care and by not providing the correct diet texture. One resident reported during interview that he had been left overnight without his brief being changed while experiencing diarrhea, despite requesting to be changed. Two CNAs separately stated that when they saw the resident the following morning, he reported not having been changed all night, that aides had come in only to change his roommate and then left, and that his skin was "raw," "pretty bad," and red. Both CNAs reported the condition of his skin to an LPN, and an order was written later that day for wound care to excoriated sacrum and scrotum every shift. Prior skin assessments from earlier in the month documented no issues to the sacrum or scrotum, and the incident was not found in the facility’s reportables or grievances. The Administrator confirmed that, if accurate, this situation would constitute neglect under the facility’s abuse policy, which defines neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. A second deficiency concerns failure to provide the correct food texture to another resident who had an active diet order for mechanical soft texture. Progress notes document that this resident was served a grilled cheese sandwich on a dinner tray, which she began to eat before an NA noticed and removed the tray. The resident coughed a few times and then was fine, and the NA obtained another tray with food the resident could eat without problem. The resident’s diet order specified mechanical soft foods, and the facility’s Diet and Nutrition Care Manual lists grilled sandwiches as foods to avoid on a mechanical soft diet. A nurse consultant later confirmed that this incident occurred as documented and that it was not reported.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to accurately post daily nurse staffing information in a prominent, accurate manner as required, with inaccuracies identified on 22 of 23 reviewed days. Upon surveyor entrance, the daily nurse staffing sheet was not readily visible and was ultimately located on a wall near the nurse’s station. Review of posted staffing sheets and time punch detail reports revealed multiple discrepancies, including incorrect dates on several postings and numerous errors in the total hours worked for various dates. On some days, corrections were written over original entries, making it impossible to clearly determine the actual number of nurse aides working or the correct total hours. In several instances, the posted total hours did not match the actual hours worked as shown on time detail reports, with both understatements and overstatements of staffing hours documented. During a nighttime observation, the posted staffing sheet listed two LPNs, three NAs, and zero RNs on duty, but a visual count showed only one LPN and two NAs actually present, with no RN. One NA was found sleeping on duty upon arrival, and another NA was in the breakroom with a makeshift office setup using a table, laptop, battery charger, and large rolling briefcase. It was later learned that one NA was assigned 1:1 to a resident, leaving two NAs to cover the remaining 56 residents. When questioned, an LPN stated that another LPN listed on the staffing sheet had called in sick due to pregnancy. These observations and documentation reviews were discussed with the Regional Director of Operations and an RN consultant, confirming that the posted staffing information did not accurately reflect the actual staffing levels and hours worked on multiple dates.
Insufficient Staffing Leading to Delayed Care and Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on all shifts to meet residents’ needs, resulting in delayed responses to call lights and inadequate incontinence care. During a resident council meeting, multiple residents reported waiting 1–3 hours for call lights to be answered, with staff sometimes stating they would return but not coming back for hours, and some residents reporting staff said they had been outside smoking with a resident. Individual resident interviews corroborated these concerns, with residents stating that night shift took a long time to answer call lights, that it could take 45 minutes to an hour or more to receive assistance, and that staff would delay changing residents during meal tray pass or after a scheduled smoke break when most aides and a nurse accompanied residents outside, leaving only one nurse to cover the floor. Staffing record reviews for specific dates showed Hours Per Patient Day (HPPD) below the minimum required 2.25 on at least one day, and the facility’s CASPER report triggered for low weekend staffing. A specific incident of neglect was identified for one resident who reported being left overnight in a soiled brief while experiencing diarrhea, despite requesting to be changed. Two CNAs independently stated that when they saw this resident the following morning, he reported not having been changed all night, and both described his skin as raw, bad, and red; one CNA stated she had changed him the previous day and that he reported no changes overnight, and both CNAs reported the condition to an LPN, who then notified an RN, leading to a wound care order for excoriation to the sacrum and scrotum. Prior skin assessments earlier in the month showed no issues in those areas, and the incident was not documented in reportables or grievances. Additionally, a night-shift observation found a discrepancy between the posted staffing sheet and actual staff present: the sheet listed two LPNs, three NAs, and no RNs, but only one LPN and two NAs were observed, with one NA found sleeping on duty and another engaged in personal business on a laptop, while a third NA was assigned 1:1 to a resident, leaving two NAs to cover 56 other residents. The administrator confirmed that the described incontinence incident would constitute neglect if accurate.
Failure to Provide Anonymous Grievance Process and Protect Residents From Fear of Retaliation
Penalty
Summary
Surveyors identified that the facility failed to honor residents’ rights to voice grievances without fear of reprisal and to provide a method for anonymous grievance submission. During a Resident Council meeting attended by 11 residents, residents reported they had no way to file an anonymous grievance, did not want to report complaints due to fear of retaliation, and felt that concerns raised in Resident Council were not taken seriously. An interview with the Social Worker confirmed there was no method for anonymous grievances and that residents and family members had to request a grievance form from a nurse or department head. Review of the facility’s Grievances/Complaints policy showed that residents and their representatives have the right to file grievances orally or in writing with facility staff or the designated agency, and that the Administrator and staff will make prompt efforts to resolve grievances, but the facility’s actual practice did not provide an anonymous option or alleviate residents’ fear of retaliation. This deficiency involved at least one identified resident (Resident #22) and the broader resident group, who reported barriers to exercising their grievance rights and lack of confidence that their concerns raised in Resident Council would be addressed, in contrast to the facility’s written grievance policy.
Failure to Follow Splinting and Blood Glucose Notification Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident with a documented right hand contracture, surveyors observed that the right hand was tightly fisted and that no splinting device was in place. Record review showed active orders to apply and remove a splint to the left hand every night shift for mobility, and the care plan directed left hand splinting as ordered, despite the medical record listing a diagnosis of a right hand contracture. During interviews, the occupational therapist confirmed the splinting order should have been for the right hand, and the Director of Nursing confirmed that both the orders and care plan were written to place a splint on the resident’s functional hand instead of the contracted hand. For another resident with an order for Humalog Kwikpen, the physician’s order specified to hold the medication for blood sugar (BS) less than 100 and to call the provider for BS over 400. Review of the Medication Administration Record for March and April showed multiple dates on which the resident’s blood sugar exceeded 400. The facility was unable to provide documentation that the provider was contacted on those dates when the blood sugar was over 400, as required by the order. A registered nurse consultant confirmed that, according to the documentation, the provider was not notified when the resident’s blood sugar readings were over 400 on the identified dates.
Food Storage and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with its own food safety and sanitation policies and professional standards. During an initial kitchen walkthrough, the surveyor, accompanied by the Director of Dining Services, observed multiple sanitation and storage issues, including a juice machine top soiled with debris, crumbs in the toaster tray, and a soiled microwave in the pantry. In the dry storage room, there was an opened, outdated brownie mix past its use-by date, and employee coats were found hanging on the bread rack. In the walk-in cooler, a case of bacon lacked an open or use-by date, and the meat slicer, though covered, had old food debris on and around the blade. The three-compartment sink log for that morning’s breakfast lacked recorded water temperature and sanitizer concentration, contrary to policy requirements for monitoring and documenting manual ware washing. Additional observations showed improper handling and storage of food and related items outside the main kitchen. A beverage in the pantry refrigerator was not labeled or dated. During a dining observation, beverage carts for two halls had trash bins placed on the same shelf as milk containers intended for residents. On a subsequent day, an employee’s coat was again found hanging on the bread rack, despite prior identification of this issue. These findings demonstrated that staff did not consistently follow facility policies requiring clean, sanitary food preparation and service areas, proper labeling and dating of TCS foods, and appropriate separation of personal items and trash from food and food-contact surfaces.
Uncovered Trash Receptacles in Food Service Areas
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards and did not follow proper sanitation practices for food preparation equipment, with the potential to affect all 60 residents. Healthcare Services Group (HCSG) Policy #28 requires all trash to be contained in covered, leak-proof containers to prevent cross-contamination, and HCSG Policy #30 requires the Dining Services Director to ensure appropriate lids are provided for all containers. During an initial kitchen walkthrough with the Director of Dining Services (DDS), the surveyor observed that the trash can beside the juice machine had no lid and that the trash can in the dish room also had no lid. The DDS confirmed both observations and acknowledged that there was no lid available for the dish room trash can.
Failure to Substantiate and Address Resident Sexual Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to appropriately use investigation results and residents’ reports to determine and substantiate sexual abuse allegations involving one male resident and two female residents. In the first incident, a cognitively intact resident reported that she awoke in her bed to find a male resident in her room, uninvited, naked from the waist down and pulling on her leg, and stated she thought he was going to try to rape her. Staff responding to her yelling found the male resident in her room wearing only a t‑shirt, with no brief or pants, and the resident told staff to remove him from her room. During examination by an NP, she again reported that a man came into her room and pulled her down in bed. Despite these observations and statements, the facility’s Five‑Day Follow‑Up report concluded that allegations of sexual abuse were not substantiated, and the facility’s position, as verified by the Administrator, was that no physical harm was done, which was the basis for not substantiating sexual abuse. The facility did not adequately evaluate whether this resident felt safe or address her expressed anxiety about the incident. In the second incident, another cognitively intact resident with a BIMS score of 14 and a physician determination of capacity reported sexual abuse by the same male resident. A CNA witnessed the male resident’s hands under this resident’s blanket, rubbing close to her private parts, and when staff intervened and asked if he had touched her private area, she stated yes. During the facility’s investigation, the resident told the Social Worker and Administrator that the male resident rubbed her private area and that she believed the contact was intentional, and she also told her attending physician that he had touched her private area. When later seen by a psychologist, she voiced no recollection of the event. The facility’s Five‑Day Follow‑Up report stated that sexual abuse could not be substantiated due to inconsistency in statements, and the Administrator confirmed that the male resident had touched her but asserted it was accidental while rubbing her leg under the blanket. The facility failed to recognize and address this resident’s expression of anxiety about the unwanted touching and did not adequately evaluate whether she felt safe, leaving her and other residents vulnerable during and after the investigative process.
Failure to Monitor and Record Food Temperatures for Always-Available Menu Items
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and maintained at a safe and appetizing temperature, as evidenced by food tray temperatures, resident interviews, and staff interviews involving four identified residents (#47, #33, #42, and #9) out of a census of 60. On 4/28/26 at 12:00 PM, it was observed that kitchen staff were not taking and recording temperatures for items on the always-available menu prior to the start of the lunch meal service. Specifically, beef patties, hotdogs, and brown gravy did not have recorded temperatures before meal service began. The Director of Dining Services acknowledged that temperatures for always-available menu items were not being taken or recorded. No additional medical history or specific clinical conditions of the involved residents were provided in the report.
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