Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at 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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Illustrative
What surveyors actually found near you
We read the 510 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Valley Oaks Care Center | 1.2 mi | ★★★★★ | 10 | 0 |
| Orchards Of East Liverpool, The | 2.5 mi | ★★★★★ | 9 | 0 |
| Calcutta Health Care Center | 5 mi | ★★★★★ | 2 | 1 |
| Beaver Valley Rehabilitation And Healthcare Center | 12.3 mi | ★★★★★ | 29 | 1 |
| Friendship Rehab And Health | 13.3 mi | ★★★★★ | 53 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.