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
- 13
- Latest survey
- August 8, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Stone Pear Pavilion during CMS and state inspections, most recent first.
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.
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.
Latest citations in West Virginia
A deficiency occurred when a lunch tray on A Hall was found to be served below required hot-holding temperature standards. During a survey, a random tray containing mashed potatoes and gravy with steak was tested by the Traveling Dietary Manager in the presence of the Administrator, and both food items measured 110°F, which did not meet required serving temperatures. The Traveling Dietary Manager and the Administrator each confirmed that the food temperature was not at the required level, and the administrative team later acknowledged this deficiency.
Surveyors found that the facility failed to provide residents with consistent and accurate readily available menus reflecting their food preferences. The Traveling Dietary Manager reported that residents could choose from multiple egg preparations, but these options were not listed on the posted menu available to residents. Additionally, the “always available” menu used in the kitchen did not match the menu provided to residents, and this discrepancy was confirmed by the Traveling Dietary Manager. The issue was identified on all menus reviewed and had the potential to affect many residents in the facility.
The facility failed to follow its abuse reporting policy when a cognitively intact resident reported that two nurses were frequently sleeping on duty and later provided an audio recording of a nurse calling the resident a "jerk." The allegation was reported by the resident to an LPN and then to an RN Infection Preventionist, but the Administrator remained unaware until the survey, and the incident was not reported to authorities within the required 2-hour timeframe. In a separate case, another resident had a verbal abuse incident reported to the state, but the facility did not complete or submit the required 5-day follow-up report, and the Administrator confirmed there was no record of that follow-up.
A resident reported unknown charges on her debit card and alleged that a former roommate had used the card without permission, estimating losses of several hundred dollars. The facility documented initial steps such as notifying external agencies, involving law enforcement, cancelling the card, separating the roommates, and assisting the resident in obtaining bank statements. However, the facility did not maintain or retain key documentation, including copies of bank statements, the total amount of funds involved, or clear follow‑up on the status and outcome of the allegation. The resident reported not receiving updates, and the BOM acknowledged that the facility lacked the resident’s financial records because they had been turned over to law enforcement and were not requested or reviewed by facility staff until shortly before the survey, resulting in an incomplete internal investigation record of the alleged misappropriation.
A resident who was cognitively intact but lacked capacity for health care decisions left the facility after breakfast and morning meds. An activities assistant saw the resident walking outside and reported this to the Manager on Duty, but no effective action was taken to verify the resident’s whereabouts or initiate a search. Nursing staff later assumed the resident was in the bathroom or out smoking when he was not in his room at mid-morning and lunchtime. The facility did not recognize the resident as missing or begin search efforts until hours later, during which time the resident hitchhiked and accepted a ride from a stranger in the community. Surveyors determined that staff had witnessed the resident outside but failed to intervene or report effectively, and that the facility remained unaware of the resident’s absence for several hours, resulting in an Immediate Jeopardy finding for neglect.
A resident who is blind and requires specific instruction during ambulation was transferred from therapy to Restorative with documented recommendations to ambulate using a walker, gait belt, and a wheelchair behind her, along with ROM and strengthening exercises. Despite a physician’s order for a Restorative Nursing Program for ambulation and ROM and the therapy recommendations communicated via an Excel spreadsheet, Restorative staff ambulated the resident without a gait belt. The resident reported becoming tired while walking, with a wheelchair behind her but not close enough, and then falling hard. She and a PTA both stated that no gait belt was used. The fall resulted in fractures to the resident’s left distal femur and right distal femur/knee area, with osteopenia noted, and the DON acknowledged that therapy recommendations had not been carried over for Restorative staff to follow.
A resident experienced multiple leg fractures after a fall, resulting in a significant change in condition and non–weight-bearing status. Although the MDS reflected that it was important for the resident to participate in group activities, favorite pastimes, and church services, the activity care plan was not revised after the injury to address her new limitations. The existing plan listed numerous preferred activities such as resident council, food committee, religious services, music, gardening, and in-room pursuits, but no new individualized interventions were added, and documentation showed only two 1:1 visits after her return from the hospital. The resident reported she could no longer get into her wheelchair, attend council or church, or join groups she enjoyed, and stated that activity staff did not visit often, while the Director of Recreation confirmed she had not attended groups since the injury and that in-room social visits were not consistently documented, resulting in a decline in activity participation and social isolation.
A resident was discharged to a motel with home health services, a wheelchair, medications, and a follow‑up medical appointment arranged, and received education on medications, blood glucose monitoring, emergency response, and home health services. Discharge planning discussions and a referral to the Take Me Home program were documented, and the facility agreed to pay for an initial period of the motel stay. However, record review and staff interviews confirmed that the resident was not given the required 30‑day written discharge notice prior to leaving, limiting the resident’s ability to prepare for discharge and exercise discharge‑related rights.
A resident sustained multiple lower extremity fractures after a fall, resulting in hospitalization, non-weight-bearing status, and loss of prior functional abilities such as standing, pivoting, and walking with therapy. Before the fall, the resident actively participated in out-of-room activities including Resident Council, food committee, church, and socials, but after returning from the hospital she no longer attended group activities and had only two documented 1:1 visits. Despite an MDS indicating a significant change in status and clear changes in activity participation, the activity care plan—last revised months earlier—was not updated with new interventions to address her altered condition and in-room activity needs, as confirmed by record review and staff interviews.
A resident with intact cognition and a history of active participation in group activities, Resident Council, and church sustained bilateral lower-extremity fractures and returned from the hospital non–weight bearing. The MDS significant change assessment and the activity care plan documented that group involvement, church services, and various preferred activities were important to the resident, yet no new interventions were added to the care plan after the change in condition. Activity participation records showed that the resident had no out-of-room activities and only two documented 1:1 visits, while the Director of Recreation acknowledged that group attendance had stopped and that in-room social visits were not consistently documented. The resident reported feeling unable to attend her usual groups, Resident Council, or church and stated that activity staff did not visit often, leading surveyors to find that the facility failed to provide an activities program that met her needs and interests following her significant change.
Improper Hot Food Serving Temperatures During Lunch Service
Penalty
Summary
The facility failed to provide resident meals at proper serving temperature during a lunch meal service on A Hall. On 03/24/26 at approximately 12:10 PM, a surveyor had a random lunch tray on A Hall temperature-tested by the Traveling Dietary Manager, with the facility Administrator present. The tested items—mashed potatoes and gravy with steak—were both measured at 110°F. During an interview at approximately 12:15 PM, the Traveling Dietary Manager confirmed that the food did not meet the required serving temperature, and at approximately 12:16 PM, the Administrator also confirmed that the food did not meet the required serving temperature. This deficiency was acknowledged by the facility’s administrative team upon survey exit on 03/25/26 at approximately 4:00 PM. No additional resident-specific clinical information or conditions were provided in the report.
Inconsistent Readily Available Menus for Resident Food Preferences
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide residents with consistent and accurate information about readily available menu items that accommodate resident preferences. During document review and staff interviews, the Traveling Dietary Manager stated that residents could choose from several egg preparations (omelet, scrambled eggs, hard-boiled egg, or hard-fried egg) as part of the facility’s readily available items. However, the posted readily available menu accessible to residents did not list these egg options. Additionally, the “always available” menu used in the kitchen did not match the menu provided to residents, and the Traveling Dietary Manager confirmed that the readily available menus did not correlate. This inconsistency was found on 2 of 2 menus reviewed and had the potential to affect more than a limited number of residents in a facility with a census of 90. On a subsequent interview, the facility Administrator acknowledged the deficiency during the exit interview.
Failure to Timely Report Verbal Abuse Allegation and Submit Required 5-Day Follow-Up
Penalty
Summary
The facility failed to follow its abuse prohibition policy requiring that allegations of abuse be reported to the proper authorities within two hours of identification and that required follow-up reports be completed. The policy defined verbal abuse as the willful use of disparaging or derogatory language toward residents or within their hearing. A cognitively intact resident with a BIMS score of 15 reported that two nurses who worked Monday through Thursday were "always sleeping" and that, after he reported this to administration, one of the nurses called him a "jerk." The resident had an audio recording dated 03/11/26 capturing a staff member calling him a "jerk" and confirming this characterization when questioned by the resident. The resident stated he informed an LPN, who then reported it to the RN Infection Preventionist. The RN Infection Preventionist acknowledged awareness of a phone conversation in which someone called the resident a jerk but stated she did not know the full details and thought it might have been discussed in a care plan meeting. The Administrator reported being unaware of the situation until interviewed by the surveyor, at which time the incident had not been reported within the required two-hour timeframe. The facility also failed to complete and submit a required five-day follow-up report for a separate allegation of verbal abuse involving another resident. Record review showed that this resident had been admitted and later discharged to the hospital, and that a verbal abuse incident involving this resident had been reported to the state agency on 04/15/25. However, review of the facility’s list of reportable incidents for one year revealed no evidence that the corresponding five-day follow-up report was ever sent. The Administrator confirmed there was no record of that reportable incident or of a five-day follow-up. These failures were identified for two of two residents reviewed for abuse, with a facility census of 67.
Failure to Thoroughly Investigate and Document Alleged Financial Exploitation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a thorough investigation and ongoing documentation of an allegation of misappropriation of resident property for one resident. Record review showed that the resident reported unknown charges on her debit card, and the facility initiated an investigation and notified OHFLAC, APS, the Ombudsman, and local law enforcement. Progress notes documented that law enforcement interviewed the resident, the resident cancelled her debit card, and she planned to obtain information from her bank. Notes also showed that the resident obtained bank statements, attempts were made to contact the investigating officer, and law enforcement later returned to obtain the resident’s banking information and ask additional questions. The facility’s 5‑day investigation report documented that the Administrator and DON reported the allegation, assisted the resident in obtaining bank statements, reviewed charges with her, identified the alleged perpetrator as the former roommate, separated the residents, and deactivated the debit card. The investigation was labeled inconclusive with law enforcement continuing the investigation, and a later Grand Jury subpoena was issued for the resident related to alleged fraudulent use of her debit card. Despite these initial steps, at the time of survey the facility was unable to provide additional documentation or evidence of follow‑up regarding the alleged misappropriation, including the total amount of funds involved, the outcome of the investigation, or any ongoing tracking of the allegation until requested by the State Agency. In interviews, the resident stated that her former roommate used her debit card without permission, estimated that approximately $800–$900 had been spent, and reported she had not received any updates about the situation. The BOM stated the facility did not have copies of the resident’s bank statements because they had been turned over to law enforcement and that law enforcement would not release information due to an ongoing investigation. In a follow‑up interview, the resident reported that no one from the facility had requested or attempted to review her bank statements, aside from law enforcement, until shortly before the interview when the BOM inquired, demonstrating that the facility did not maintain documentation necessary to determine the extent of the alleged misappropriation. A staff member later provided a written statement that they accompanied the resident to a Grand Jury proceeding related to fraudulent use of the debit card, but the facility still lacked internal documentation of the scope and outcome of the allegation.
Failure to Respond to Known Resident Elopement and Prolonged Unnoticed Absence
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not responding to a known elopement. A cognitively intact resident, who had a BIMS score of 14 but had been deemed by the physician to lack capacity to make health care decisions, left the facility in the morning after having breakfast and receiving morning medications. The resident’s elopement risk evaluation score was 0, indicating low risk for elopement, and the MDS indicated no wander/elopement alarm was used less than daily. The resident’s care plan identified adjustment issues related to change in lifestyle and difficulty accepting placement, with interventions focused on coping and adjustment, but did not identify elopement risk prior to the incident. At approximately 9:00 AM, an activities assistant saw the resident walking outside down a public street near a store. The activities assistant contacted the social worker, who was the Manager on Duty, shortly thereafter to report the resident’s location. The activities assistant then clocked in for her shift around 9:03–9:05 AM. Despite this report, no effective action was taken by facility staff at that time to verify the resident’s whereabouts, intervene, or initiate a search. The social worker later stated she did not realize anything was going on until early afternoon, explaining that she missed the information about the resident being at the store while she was talking with other residents during the phone call. During the period from roughly 9:15 AM to 1:55 PM, there was a delay in supervision and monitoring of the resident. The LPN assigned to the resident reported administering morning medications and exchanging pleasantries with the resident earlier that morning, consistent with the facility’s elopement timeline. The CNA assigned to the resident stated that the resident was in the room during breakfast, but when she entered the room around 10:30 AM to provide a snack to the roommate, the resident was not present and she assumed he was in the bathroom. At lunchtime, when the CNA did not see the resident, she assumed he was out smoking. The facility did not recognize the resident as missing or initiate search or recovery actions until approximately 1:30 PM, when the activities assistant reported that the resident was not present for a smoke break. The State Agency determined that staff had witnessed the resident outside the facility but failed to intervene or report effectively, and that the facility remained unaware of the resident’s absence for about 4.5 hours, creating an Immediate Jeopardy situation due to the resident being unsupervised in the community for an extended period. The resident later reported that he was attempting to travel to another town to attend to personal business, hitchhiking to a nearby city and then walking further when he found the bus station closed. He described being offered a ride and food by a man who drove him to a restaurant, where he was eventually picked up by someone from the nursing home. The State Agency concluded that the facility’s failure to act on the known elopement and to promptly identify and respond to the resident’s absence constituted neglect and placed the resident at immediate risk for serious harm or death.
Failure to Use Gait Belt During Restorative Ambulation Resulting in Resident Fractures
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice when a resident participating in Restorative Therapy ambulation was walked without a gait belt, contrary to therapy recommendations. Record review showed the resident experienced a fall and was sent to the emergency room with pain in both legs, where diagnostic imaging revealed an anterior apex angulated distal femur diametaphyseal fracture with impaction in the left femur and an impaction and comminuted anterior apex angulated fracture of the distal fifth metaphysis in the right knee, with osteopenia noted. The resident, who is blind and requires specific instruction when ambulating, had been transferred from therapy to Restorative with recommendations documented on an Excel spreadsheet to ambulate with a walker, gait belt, and wheelchair behind the resident, up to 70 feet, along with ROM and strengthening exercises. A physician’s order for a Restorative Nursing Program for ambulating and ROM was in place, with the expectation that Restorative staff would refer back to therapy’s recommendations for safety measures. Interviews confirmed that on the day of the fall, staff ambulated the resident without a gait belt. The PTA identified the location of the fall and stated that a gait belt had not been used while walking the resident. The DOR reported that therapy staff had always used a gait belt with this resident and that the recommendation to use a gait belt was communicated via the Excel spreadsheet used by Restorative Therapy to receive therapy orders and recommendations. The resident, who had a BIMS score of 15 and thus had capacity, stated that she became tired while walking with Restorative staff, that a wheelchair was behind her but not close enough, and that she fell hard; she reported that staff did not have a gait belt on her and believed that if a gait belt had been used, she would not have fallen so hard. The DON stated she was not aware of the Excel spreadsheet and confirmed that therapy recommendations were not carried over for Restorative Therapy to follow.
Failure to Revise Activity Care Plan After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received ongoing opportunities to participate in meaningful activities consistent with her interests and preferences following a significant change in condition. The resident experienced a fall on 02/18/26, was sent to a local emergency room for pain in both legs, and diagnostic radiology revealed an anterior apex angulated fracture of the distal left femur with impaction and an impaction and comminuted anterior apex angulated fracture of the distal right femur metaphysis, with osteopenia noted. She was hospitalized for these fractures and returned to the facility on 02/24/26. A subsequent MDS with an ARD of 02/27/26 documented a significant change in status and indicated that it was important for the resident to do things with groups of people, participate in her favorite activities, and attend church services. Record review showed that the resident’s activity care plan, originally initiated in 2020 and revised multiple times through 03/03/2025, contained numerous interventions reflecting her preferences, including in-room visits, participation in food committee and resident council, church and religious services, group singing and cooking, gardening, pet visits, listening to religious/bluegrass/country music, watching TV and keeping up with the news, and engaging in favorite activities such as church, sewing, cooking, reading, and gardening. The care plan also noted her use of a wheelchair and need for accommodations for visual impairments. However, there were no new or revised activity interventions added to address her new non–weight-bearing status and functional limitations after the fractures, and no changes to the activity care plan were documented following the significant change in condition. During interview, the resident, who had decision-making capacity and a BIMS score of 15, reported that prior to the fall she had been able to stand, pivot, and walk with therapy, and that she had been active in resident council, church, and social activities. She stated that since her return from the hospital she could not get into her wheelchair, could not attend resident council meetings or church, and could not participate in the group activities she enjoyed. She reported that activity staff did not visit her very often and became tearful while describing her situation. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital, was non–weight-bearing for 10 weeks, and that anything done with her was now in-room. The Director of Recreation also stated that the resident did not receive one-to-one visits “per se” and that social visits were not documented. Surveyors identified that only two one-to-one visits had been documented since the resident’s return from the hospital and that there was a significant decline in her activity participation without corresponding revisions to her care plan, which led to the finding of failure to provide consistent, individualized activity interventions and ongoing opportunities for meaningful activities.
Failure to Provide Required 30‑Day Written Discharge Notice
Penalty
Summary
The facility failed to provide a required 30‑day written discharge notice to a resident prior to discharge. A complaint was received by the State Agency stating that the resident was being discharged to a hotel and that the facility would pay for the first 28 days, after which the resident would be responsible for their own expenses. The complainant reported the resident had no income and uncertainty existed about how the resident would obtain food and medications. Record review showed that on one date, Social Services documented discharge planning discussions and a referral to the Take Me Home program at the resident’s request, and an assessment note indicated discharge planning documentation was completed. Further record review revealed that on the day of discharge, Social Services documented that the resident was discharged to a motel with home health services arranged, a wheelchair provided, medications supplied, and a follow‑up appointment scheduled. Nursing documentation from the same day showed the resident received education on medications, blood glucose monitoring, emergency response, and home health services prior to discharge. However, there was no evidence in the medical record that the resident was provided a written 30‑day discharge notice before leaving the facility. In an interview, the Social Worker, in the presence of the Administrator, confirmed that the resident had chosen discharge to a motel and that the facility paid for 28 days at the hotel and provided 14 days of medications, and also confirmed that a 30‑day discharge notice was not issued. The deficient practice had the potential to affect the resident by limiting the ability to adequately prepare for discharge and exercise rights regarding the discharge process.
Failure to Update Activity Care Plan After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to update an activity care plan following a resident’s significant change in condition and participation. The resident experienced a fall on 02/18/26, resulting in fractures to the left distal femur and right distal femur/knee, with osteopenia noted on diagnostic imaging. She was hospitalized and returned to the facility on 02/24/26. A subsequent MDS with an ARD of 02/27/26 identified a significant change in status. Despite this, the resident’s activity care plan, originally initiated in 2020 and revised multiple times through 03/03/2025, was not revised after the fall and significant change to reflect her new limitations and altered participation in activities. Prior to the fall, the resident had been able to stand, pivot, and transfer to her wheelchair, and was walking up to 100 feet with therapy. She was active in out-of-room activities, including Resident Council, food committee, parties, socials, church, and other group activities. After the fall, she reported that she now had a rod in her left leg, a brace on her right leg, and was non-weight bearing for 10 weeks, which prevented her from getting into her wheelchair and attending the activities she previously enjoyed. She expressed distress about no longer being able to attend Resident Council meetings, church, and family gatherings, and stated that activity staff did not visit very often and that she could not go out to the groups she liked. During the interview, she was observed to be tearful. Record review of activity participation from 01/01/2026 to the present showed that the resident had participated in out-of-room activities before the fall but had no out-of-room participation after her return from the hospital. The records also showed that since the significant change, she had only two documented one-to-one visits, both on 03/04/26. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital and was non-weight bearing, and stated that anything done with her was now in-room. The Director also stated that social visits were not documented as one-to-one visits. Surveyors noted that there were no new or revised interventions on the activity care plan since 01/2025 despite the significant change in the resident’s condition and participation, and the Administrator and Director of Recreation confirmed that the documentation reflected this lack of update.
Failure to Adjust Activities Program After Resident’s Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to provide an activities program that met the interests and needs of a resident who experienced a significant change in condition and activity participation. The resident, who was cognitively intact with a BIMS score of 15 and served as president of the Resident Council, sustained fractures to the left distal femur and right distal femur/knee area after a fall and was hospitalized. Diagnostic imaging showed an anterior apex angulated, impacted distal femur diametaphyseal fracture on the left and an impacted, comminuted anterior apex angulated fracture of the distal fifth metaphysis of the right knee, with osteopenia noted. After hospitalization, the resident returned to the facility and had an MDS with a significant change assessment, with Section F indicating that it was important for her to do things with groups of people, participate in favorite activities, and attend church services. Record review showed that prior to the fall and fractures, the resident participated in out-of-room activities, including Resident Council, food committee, parties, and socials. The activity care plan, originally created in 2020 and revised multiple times through early 2025, documented numerous preferences and important activities for the resident, such as in-room visits, participation in food committee, church, singing, cooking, gardening, going outside in good weather, pet visits, listening to religious and other music, watching TV, reading, and engaging in religious services and voting. The care plan also noted that it was important for her to engage in her favorite activities and to have opportunities to make choices related to meaningful activities. However, there were no new interventions added or changes made to the activity care plan after her significant change in condition and return from the hospital. Activity participation records from the beginning of the year through the time of survey showed that since her readmission from the hospital, the resident had no out-of-room activity participation and only two documented one-to-one visits, both on the same day. During interview, the resident reported that she could no longer stand, pivot, or get into her wheelchair, and that she was now unable to attend Resident Council meetings, church, or be around people as she had before. She expressed distress about missing family gatherings she had been working toward attending and stated that activity staff did not visit very often and that she could not go out to the groups she liked. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital due to being non–weight bearing, that anything done with her was now in-room, and that social visits were not consistently documented. The Administrator and Director of Recreation acknowledged that documentation showed only two one-to-one visits and no updated interventions on the care plan since before the significant change, leading to the finding that the facility failed to provide a program of activities to meet this resident’s needs and interests after her change in condition.
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