Stone Pear Pavilion

Based on observation and staff interview, the facility failed to ensure proper infection control practices were completed during medication administration and hand hygiene for staff between passing trays and offering residents hand hygiene on the resident halls. These were random opportunities for discovery. Facility Census: 56. Findings Include: a) Medication Administration On 03/04/26 at 9:39 AM, an observation of Registered Nurse (RN) #26 preparing medication for Resident #3 was made. During the observation, RN #26 dropped a pill (Zoloft) directly on the medication cart, which had no barrier, and picked the pill up with a bare hand. RN #26 did not complete hand hygiene before or after administering the medication. On 03/04/26 at 10:00 AM, the Director of Nursing (DON) was notified and confirmed the medication should have not been picked up with a bare hand and a barrier should be used on the medication cart. The DON, also, confirmed hand hygiene should have been completed before and after medication administration had been completed. a) Staff hand hygiene The facility's policy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, resident interview, and staff interview, the facility failed to ensure documentation the physician was notified when the resident experienced a change in condition. Resident Identifier: #2. Facility Census: 56. Findings included: a) Resident #2 On 03/02/2026 at 3:45 PM, Resident #2 stated she wanted to see the physician today regarding bleeding, but she thought the physician had already left for the day without seeing her. She stated she wasn't sure if the bleeding was vaginal bleeding or urinary bleeding. Review of Resident #2's electronic health records showed the following nursing notes:-Written on 02/28/2026 at 10:45, Small amount of dark red discharge noted from vaginal area during AM [morning] care.- Written on 03/2/2026 at 9:02 AM, CNA [Certified Nursing Aide] reports vaginal blood noted when placing resident on bed pan. RN [Registered Nurse] in room to assess, dried blood noted to thighs and vagina. blood noted in Residents urine after getting off the bed pan. Nurse practitioner to evaluate upon rounds this AM. Resident afebrile. On 03/04/26 at 4:29…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and staff interview, the facility failed to store medications within acceptable standards of care. A bottle of Aplisol (tuberculin purified protein derivative) located in refrigerator in med room had been opened more than 30 days ago. This was a random opportunity for discovery during the facility task of medication storage and labeling. Facility Census: 56. Findings included: On 03/02/26 at 9:30 AM, the medication preparation room was inspected with Licensed Practical Nurse (LPN) #41 in attendance. An opened multi-use vial of Aplisol (tuberculin purified protein derivative) was in the refrigerator. Aplisol is used to diagnosis tuberculosis. The bottle had an opening date written on it. The opening date was 01/23/26. The medication packaging insert was no longer with the vial. According to Aplisol packaging insert, available on-line on the Food and Drug Administration (FDA) website, Vials in use for more than 30 days should be discarded. LPN #41 confirmed the Aplisol vial was out of date since it had been opened 01/23/26. She stated she would…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and staff interview, the facility failed to meet the nutritional needs of the residents in accordance with established national guidelines due to not following the menu. The facility failed to follow the approved menus, making random substitutions of food items. This had the potential to affect more than a limited number of residents. This is true for Resident #51, Resident #35 and Resident Council. Facility census: 56.Findings include: a) 03/03/2026 11:55 AM Resident #51 states the food is cold and bad. I am a diabetic and need to be on a diabetic diet. I have never seen a dietitian since I have been here. At 1:30 PM following the resident council meeting, Resident #51 gave me her tray ticket and let me know that it did not match the copy of the menu that she was given by the facility to keep in her room. She also did not receive the corn chowder that was on her tray ticket. She received vegetable soup. She said that she wasn't allergic to anything in the vegetable soup, but what if I would have been, or what if someone that has dementia received…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview, the facility failed to provide a safe, sanitary, and homelike environment. This was a random opportunity for discovery. Room identifier: east and west shower rooms. Facility census: 58. Findings include: a) East Shower Room During an interview with Resident #1 on 08/06/24 at 12:46 PM she stated the shower room had mold on the floor and up the walls. She continued to say she did not like to put her feet down because they do not clean the shower room very well. An observation, on 08/06/23 1:33 PM, of the east shower found a black substance on the floor and up the walls, and a thick layer of lent and debris on the ceiling vents. During an interview on 08/06/24 at 2:15 PM the Environmental Services Supervisor confirmed the shower room floor, walls, and vents needed cleaned. She stated, It's hard to keep up on because of the moisture in the room, so they power wash the black substance off the floors and walls once a month. b) [NAME] wing shower room Inspection of the [NAME] wing shower room on 08/06/24 at 2:10 PM revealed a black substance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and staff interview, the facility failed to provide care and services in accordance with acceptable standards of practice. The facility failed to ensure the physician was notified when Resident #56's blood sugar levels were above 400. This affected one (1) of five (5) residents reviewed for unnecessary medications during the long-term care survey process. Additionally, the facility failed to have matching treatment orders when comparing the Physician Orders for Scope of Treatment (POST) form and written physician orders on the chart. This was true for one (1) of 19 residents reviewed in the Long-Term Care Survey Process. Resident identifiers: #56 and #3. Facility census: 58. Findings included: a) Resident #56 During a resident representative interview on 08/06/24 at 12:01 PM, it was discovered Resident #56 occasionally had high blood sugar levels. A record review, completed on 08/07/24 at 1:59 PM, revealed the following physician order: NovoLOG FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML. Inject subcutaneously before meals and at bedtime for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of the staff schedules for Registered Nurse (RN) coverage and staff interview, the facility failed to ensure RN coverage eight (8) consecutive hours a day, seven (7) days a week. This had the potential to affect all residents at the facility. Facility census: 58. a) RN Coverage A review of the staffing schedules for RN coverage, completed on 08/08/24 at 12:30 PM, revealed ten (10) occasions when RN coverage did not occur eight (8) consecutive hours a day: 01/13/24 - RN Coverage was 7.00 hours 01/14/24 - RN Coverage was 7.00 hours 02/03/24 - RN Coverage was 6.00 hours 02/04/24 - RN Coverage was 6.00 hours 02/11/24 - RN Coverage was 6.00 hours 02/25/24 - RN Coverage was 0.00 hours 03/09/24 - RN Coverage was 7.00 hours 03/23/24 - RN Coverage was 6.25 hours 03/30/24 - RN Coverage was 6.75 hours 03/31/24 - RN Coverage was 7.00 hours During an interview on 08/08/24 at 2:50 PM, the Administrator reported the facility was unable to produce evidence of RN coverage for eight (8) consecutive hours on the above-mentioned dates.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview the facility failed to have a clean sanitized mobile utility food cart and debris under the kitchen prep tables, the stove and [NAME]. This had the potential to affect all residents that get their nutrition from the kitchen. Facility census. 58. Findings included: a) Kitchen tour During Initial tour on 08/06/24 at 9:44 AM found: 1- One (1) mobile utility cart with the toaster, having old food and other debris on all three (3) shelves. 2-old food and debris under prep tables, the stove and [NAME]. An Interview with the Dietary Manager during initial tour verified all issues noted. She stated that she was unaware of the issues, and she would fix the issues.

Based on record review and resident interviews, the facility failed to ensure residents had the right to make choices about aspects of their life in the facility that are significant to the resident, including the right to participate in social, religious, and community activities that do not interfere with the rights of other residents in the facility. This was true for two (2) of five (5) residents reviewed for the category of choices, during the long-term care survey. Resident Identifiers: #25 and #40. Facility Census: 58. Findings Included: a) Resident #25 During an interview on 08/06/24 at 11:05 AM, Resident #25 revealed she would like to have three showers a week, but the facility only schedules her for showers on Tuesdays and Saturdays. She stated that she had mentioned her preference to the Nursing Assistants (NAs) on more than one occasion, but her requests had been ignored. Record review revealed a shower schedule for the facility's East Wing with Resident #25 scheduled for showers on Tuesdays and Saturdays in the AM. In an interview with NA #42 on 08/07/24 at 12:06 PM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review and policy review the facility failed to make prompt efforts to resolve a grievance and to keep the resident notified of progress toward resolution. This was true for one (1) of three (3) grievances reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifier: #55. Facility census: #58. Findings Include: a) Policy Review Record review of the facility's policy titled, Grievance, revision dated 09/14/22, showed: -Upon receipt of an oral, written or anonymous grievance submitted by a Resident, the grievance official will take immediate action to prevent further potential violations of any residents' rights while alleged violation is being investigated, if indicated. -The Grievance Committee / Grievance official shall complete an investigation of the resident's grievance. This may include a review of facility processes, programs and policies, as well as interviews with staff, residents, and visitors, as indicated. And any other review deemed necessary by the Grievance Committee. -The facility will keep evidence of the resolution of all…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and staff interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for one (1) of 19 residents reviewed during the Long-Term Care Survey process. The MDS for Resident #36 did not accurately reflect the resident had bilateral hearing amplifiers. Resident identifier: Resident #36. Facility Census: 58. Findings included: a) Resident #36 During an interview, on 08/06/24 at 1:15 PM, Resident #36 reported, she was hard of hearing and was dependent on bilateral hearing amplifiers to hear better. Resident #36 stated, the Social Worker had helped her purchase the hearing amplifiers. The Social Worker reported the resident had her bilateral hearing amplifiers since 05/16/24. A review of Resident #36's Medicare - 5 Day MDS, with an Assessment Reference Date (ARD) of 06/23/24, revealed Section B titled Hearing, Speech, and Vision, answered Question B0300 titled Hearing Aid as: No. During an interview on 08/08/24 at 11:12 AM, MDS LPN #57 acknowledged the MDS with ARD date of 06/23/24 had incorrectly coded NO to Question B0300…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure that the resident's Pre-admission Screening (PAS) reflected pre-admission diagnoses for one (1) of one (1) residents reviewed for the category of PASRR (Pre-admission Screening and Record Review), during the Long-Term Care Survey process. Resident identifier: #58. Facility census: 58. Findings included: a) Resident #58 A record review, completed on 08/06/24 at 12:53 PM, revealed Resident #58 had been admitted to the facility on [DATE] with an admitting diagnosis of Major Depressive Disorder. The admitting Pre-admission Screening and Resident Review (PASARR), dated 05/08/24, did not identify Resident #58 had a major depressive disorder on Section III, Question 30 of the PASRR. This PASRR indicated no Level II was required. A continued record review also revealed a there was never a new PAS completed to reveal resident's major depressive disorder diagnosis in order to address whether or not specialized services were needed. During an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to identify and implement measures to reduce hazards and risks, and to ensure that the resident environment remained free of accident hazards. This failed practice had the potential to affect more than a limited number of residents who resided at the facility. This was a random opportunity for discovery. Facility census:58. Findings Included: a) On 08/06/24 at 1:24 PM, it was observed that two bathrooms in close proximity to the physical therapy room, and conference room/lounge, were unlocked and accessible to both staff and residents at any time. Upon further inspection, it was discovered that these bathrooms were not equipped with nurse call devices or emergency pull alarms. During an interview with Administrator #72 on 08/06/24 at 1:39 PM, he stated that Those bathrooms are not for residents. When asked what prevented residents from using those bathrooms, he could not provide a reason. However, he mentioned that if residents did use the bathrooms, they were equipped with grab bars for safety. He also mentioned that these…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to provide services to provide appropriate toileting schedule for one (1) of one (1) resident reviewed for the bowel and bladder care area during the long term care survey. Resident identifier #32. Facility census: 58. Findings include: a) Resident #32 During an interview 08/06/24 at 12:53 PM with Resident #32's sister, she stated, the staff don't take her to the bathroom when she needs to go. She continued to say her sister has accidents because they make her wait. A Medical record review found a physician order dated 9/6/22: Toilet upon rise, before meals and after meals at bedtime (HS) as needed if voiced. A continued review of Activities of Daily Living (ADL's) Toileting documentation showed Resident #32 was only toileted two (2) times a day. During an Interview on 08/08/24 at 11:00 AM, Minimum Data Set Coordinator #57 verified, the documentation of toileting did not follow the active physicians order.

Based on interview and review of documents, facility failed to adequately assess and control resident's pain. This failed practice had the potential to cause harm to one (1) of two (2) residents reviewed for pain. Resident #13. Facility Census: 58. Findings included: a) Resident #13 During an interview with Resident #13 on 08/06/24 11:32 AM, Resident #13 stated that she had fractured her right ankle and previously a cast on her leg. She stated that the cast had been removed on 08/02/24 and a cam walker boot had been applied. Resident was seated in a wheelchair and stated that she was in pain. She rated her pain at a level of ten (10) on a scale of ten (10). LPN #60 stated that she was aware and administered Acetaminophen 650 MG as prescribed. When this surveyor performed a follow-up interview with the resident at 12:55 PM, the resident was in bed, and rated her pain as five (5) on a scale of ten (10). During an interview with LPN #60 she stated, she always rates her pain high. Document review revealed a physicians note dated 6/24/2024 at 3:03 PM which stated: I certify that all…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility documentation and staff interview, the facility failed to have the required members attend the Quality Assessment and Assurance (QAA) meetings at least quarterly. The facility failed to ensure the Medical Director or designee attended the QAA meetings at least on a quarterly basis. This practice had the potential to affect more than a limited number of residents. Facility census: 58. Findings included: a) Quarterly QAA Meetings During an interview on 08/08/24 at 2:20 PM, the Director of Nursing and Administrator reported the the facility had QAA Meetings on a quarterly basis. Sign in sheets for QAA meetings were reviewed from August 2023 through August 2024. The sign in sheets for the meetings showed no attendance, by signature, of the Medical Director or designee for the quarter for January 2024 through March 2024. The DON reviewed for the minutes for the 01/24/24 QAA meeting and failed to find any evidence the Medical Director was present.

Based on policy review, record review and staff interview The facility failed to develop and implement policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. In addition, pharmacy recommendations were kept in the Director of Nursing's (DON) office and not forwarded to the physician for a timely response. This is true for one of five reviewed for unnecessary medications, but has the potential to affect all residents. Resident identifier: #51. Facility census: 56. Findings include: a) Facility policy The undated facility policy titled Village Long Term Care Pharmacy Services Policy and Procedures for Documentation and Communication of Consulting Pharmacist Recommendations states pharmacist recommendations regarding residents' drug therapy are communicated to those with authority and/or responsibility to implement the recommendations, and respond to in an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on Resident Council Interview, observation, resident interview, staff interview, record review and documentation review the facility neglected to have a system in place for Residents to notify staff when outside on the patio. Resident identifier: #7. Facility census: 56. Findings included: a) Non-Functioning Doorbell/Call System During an interview on 09/13/22 at 2:00 PM, Resident Council identified a concern related to re-entry back into the facility from the patio area. Resident Council disclosed that the doorbell does not work, and most Residents cannot physically open the door to go back into the facility. Resident Council stated that Residents had to wave to alert the staff to get back inside the facility from the patio. An observation on 09/13/22 at 2:20 PM showed Resident #7 sat outside alone. An observation on 09/13/22 at 2:20 PM of the patio door doorbell revealed no sound when pushed. The doorbell located beside the patio door was pushed by two (2) Surveyors multiple times over a 15-minute…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and operation policy the facility failed to report alleged violation related to, neglect, or abuse, and report the results of all investigation to the proper authorities within prescribe time frames. This was a random opportunity for discovery. Resident identifier: #1. Facility census: 56. Record review of the facility's policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, showed: -It is the facility's policy to investigate all allegations involving Abuse, Neglect, Exploitation & Misappropriation of Resident Property, including injuries of unknown source, in accordance with this policy. -Facility staff should immediately report all such allegations to the Administrator and to [NAME] Virginia Office of Health Facility Licensing and Certification (OHFLAC) in accordance with the procedures in this policy. -If Abuse or serious Bodily Injury is Alleged. If the event that caused the allegation involves an allegation of Abuse or serious bodily injury, it should be reported to OHFLAC immediately, but not later than two…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and operation policy the facility failed to take actions to investigate an alleged violation related to, verbal abuse. This was a random opportunity for discovery. Resident identifier #1. Facility Census 56. Record review of the facility's policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, showed: -It is the facility's policy to investigate all allegations involving Abuse, Neglect, Exploitation & Misappropriation of Resident Property, including injuries of unknown source, in accordance with this policy. -Facility staff should immediately report all such allegations to the Administrator and to [NAME] Virginia Office of Health Facility Licensing and Certification (OHFLAC) in accordance with the procedures in this policy. -If Abuse or serious Bodily Injury is Alleged. If the event that caused the allegation involves an allegation of Abuse or serious bodily injury, it should be reported to OHFLAC immediately, but not later than two (2) hours after the allegation is made. Findings include: a) Resident #1 An…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview the facility failed to provide Notice of Discharge to the Office of the State Long Term Care (LTC) Ombudsman during a discharge / transfer or the Resident Representative. This was true for two (2) of three (3) Hospitalizations reviewed. Resident Identifier #40 and #54. Facility Census 56. Findings Included: a) Resident #40 Record review on 09/13/22 at 1:27 PM, revealed resident #40 was discharged to the hospital on [DATE] and 09/02/22. Subsequent review of the resident #40's medical record showed it did not contain documentation that the Notice of Transfer or Discharge was provided to the Resident Representative, or the Ombudsman of the discharges on 08/28/22 or 09/02/22. b) Resident #54 Record review on 09/13/22 at 1:27 PM, revealed resident #54 was discharged to the hospital on [DATE]. Subsequent review of the resident #54's medical record showed it did not contain documentation that the Notice of Transfer or Discharge was provided to the Resident Representative, or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, medical record review and staff interview, the facility failed to implement a care plan. Resident #50's foot brace was not applied when up in her wheel chair. This was a random opportunity for discovery. Resident identifier: #50. Facility census: 56. Findings include: a) Resident (R) #50 Observations on 09/12/22 at 3:00 PM and on 09/13/22 at 10:00 AM, found R# 50 in her wheel chair without a right foot brace. Review of the medical record on 09/13/22 revealed R #50 had a stroke affecting her right dominant side. The care plan updated on 08/18/22 states Brace to right foot when up in w/c (wheel chair). During an interview on 09/13/22 at 1:30 PM, Licensed Practical Nurse (LPN) #7 and LPN #82 confirmed R #50's care plan includes an intervention to place the right foot brace on when she is up in her wheel chair. LPN #82 acknowledged R# 50 has not been wearing her foot brace. .

Based on observation, medical record review, and staff interview the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. Physician orders were not followed for the application of a foot brace when up in a wheel chair. This was a random opportunity for discovery. Resident identifier: #50. Facility census: 56. Findings include: a) Resident (R) #50 Observations on 09/12/22 at 3:00 PM and on 09/13/22 at 10:00 AM, found R #50 up her wheel chair without a right foot brace. Review of the medical record on 09/13/22 revealed R #50 had a stroke affecting her right dominant side. A physician order written 08/04/22 states Brace to right foot while up in chair. During an interview on 09/13/22 at 1:30 PM, Licensed Practical Nurse (LPN) #82 reported R #50 has not been wearing her foot brace. LPN #7 confirmed R #50's physician orders include directions to place a right foot brace when she is up in her wheel chair and acknowledged the medical record lacks information indicating R #50's refusal to wear the brace. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Weekly pressure ulcer assessments were not completed. This is true for one of three reviewed for pressure ulcers. Resident identifier: R #106. Facility census: 56. Findings include: a) Resident (R) #106 Review of the medical record on 09/13/22 revealed R #106 was readmitted to the facility on [DATE]. The wound nurse's initial visit / assessment dated [DATE] states R #106 was admitted to the facility with two pressure ulcers. The left heel had an unstageable 3.1 centimeter (CM) long by 2.9 cm wide pressure ulcer with a black eschar wound bed. The left second toe had an unstageable 0.4 cm long by 0.3 cm wide pressure ulcer with a black eschar wound bed. The physician history and physical dated 09/01/22 identifies a stage 2 pressure ulcer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and staff interview the facility failed to store oxygen tubing in the appropriate bag when not in use and ensure there was a physician order to administer oxygen to a resident. This was a random opportunity for discovery. The failed practice had the potential to affect a limited number of residents. Resident identifier: #10. Facility census: 56. Findings included: a) Resident #10 An observation on 09/12/22 at 4:57 PM showed Resident #10 laid in bed with nasal cannula in place and oxygen being administered at four (4) liters per minute. An observation on 09/13/22 at 10:21 AM showed Resident #10 was not in room and the oxygen nasal cannula tubing was stored on top of concentrator and not in the storage bag that was present. Review of Resident #10's medical record showed there was no current physician order for oxygen administration. An observation on 09/13/22 at 12:03 PM, showed Resident # 10 was sitting in wheelchair with oxygen being administered via nasal cannula with wheelchair oxygen canister. The bedside oxygen concentrator was also beside bed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.