Every finding on record at Stone Pear Pavilion

Based on observation and staff interview, the facility failed to store and dispose of garbage and refuse properly. The dumpster had two sliding doors that were both open. The lid on the trash can located in the kitchen was not on securely, during two different observations of the kitchen during the survey process. This was a random opportunity for discovery that has the potential to affect every resident at the facility. Facility census: 56. Findings include:a) On 03/02/2026 at 12:11 PM, the lid on the trash can located in the kitchen was not on securely. Employee #100 acknowledged that it should be on securely when not in constant use.On 03/03/2026 at 12:35 PM, the lid on the trash can located in the kitchen was not on securely. Employee #100 acknowledged that it should be on securely when not in constant use.On 03/03/2026 at 12:55 PM, both sliding doors were opened on the dumpster. Employee #100 stated we got to start closing the doors.

Based on record review, resident interviews and staff interviews, the facility failed to ensure all food was temped before leaving the kitchen, to ensure safe food temperatures to prevent foodborne illness and an appetizing temperature of the food. The facility failed to ensure hot foods were served hot and cold foods were served cold. This failed practice had the potential to affect all of the residents. Facility census: 56 Findings include: a)The facility is not following state or federal guidelines, or their own policy for taking and recording food temperatures on all food items prepared in the dietary department, before serving the residents these items. Their policy states: No food will be served that does not meet the food code standard temperatures. They do not know if the temperatures meet the food code standards, because they were not taking all of them per the guidelines. 03/02/2026 at 11:40 AM This surveyor asked to see the the food temperature logs. There were none documented for the Month of March 2026. The Director of Dining filled them in. The food temperature logs only have five (5) sections to document food temperatures. One starch, one protein, one dessert, one drink and one vegetable. The kitchen does not take the temperature and record them for any other food item that is prepared and sent to the residents, including all mechanically altered foods. Employee #100 acknowledged this concern and made a new temperature log to start using after the staff have been in serviced. b) Resident Council on 03/03/2026 at 1:00 PM The residents attending this meeting stated the food is not hot. c) Resident #51 states the food is cold and bad.

Based on observation and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety. Additionally, the facility failed to follow the proper sanitation practices for the kitchen and the food preparation equipment. This practice had the potential to affect all of the residents. Facility census: 56.Findings include: a) 03/02/2026 11:35 AM Initial walkthrough of the kitchen The Director of Dining (DOD) accompanied the surveyor during and acknowledged the following findings to be accurate. The facility did not follow the FDA Food Code or their own policies for the following: The three fan guard covers in the walk in refrigerator are soiled with debris and needed to be cleaned.The air filter covers on the ice machine had dust and debris.Two (2) packages of rolls not dated on the bread rack.The can opener was soiled.One (1) oven rack was sitting directing on the floor.Both ovens needs to be cleaned. Heavy debris buildup found.The shelf below the flat top was soiled.One (1) opened container of mozzarella cheese had an open date but no use by date.A tray holding around twenty beverages that were poured, milk and juice, were not labeled or dated in the walk in refrigerator. One (1) bag of bacon bits did not have an open or use by date.One (1) bagged lunch was not dated.One (1) container of beef stew was outdated with a use by date of 03/01/2026.Two (2) bags of cinnamon rolls located in the freezer were not labeled or dated.One (1) opened bag of onion rings was not dated or sealed tightly.Three (3) beef briskets were not dated in the freezer.Two (2) packages of croissants were not dated.One (1) container of hot dogs located in the freezer was not labeled or dated.At 12:05 PM The low temp dish machine was 109 degrees F, 110 degrees F and 113.6 degrees F. The federal regulation, the manufactures recommendation and the facilities policy states that the low temperature dish machine needs to be at a minimum of 120 degrees F.The shelf located under the soda dispenser was soiled and needed to be cleaned.One (1) container of cream cheese was outdated with a use by date of 02/12/26.Ten or more spices did not have open or use by dates.Five (5) spices were not closed tightly. One (1) dented can of spaghetti sauce was in the food storage room. The facility did not have a designated are for dented cans.Both toasters needed the crumb trays to be cleaned out.There was no kitchen / equipment cleaning schedule posted.03/03/26 at 12:30 PM Follow up visit to the kitchen findings include: Two (2) employee beverages sitting beside the microwave in the kitchen.The can opener base was soiled.Two (2) sandwiches not labeled or dated in the sandwich cooler.Two (2) bowls of coleslaw were not labeled and did not have a use by date.One (1) container of diced cucumbers without a label or use by date.One (1) container of diced green bell peppers without a label or use by date.One (1) container of diced tomatoes without a label or use by date.One (1) container of fruit salad without a label or use by date.One (1) container of applesauce without a date.One (1) unknown beverage not labeled in the reach in refrigerator.One (1) container of crushed pineapple without a use by date.Fourteen bowls of assorted soups with no use by date.One (1) container of chocolate pudding without a use by date.One (1) container of vanilla pudding without a use by date.Six (6) gallons of opened assorted salad dressings without a use by date.One (1) container of mustard without a use by date.One (1) container of sweet n sour sauce without a use by date.One (1) container of pickles without a use by date.One (1) container of sweet chili sauce without a use by date.One (1) container of ham salad without a open or use by date.One (1) container of olives not dated.One (1) container of tartar sauce not dated.One (1) container of unknown food not labeled and did not have a use by date.One (1) steam table pan of boiled eggs not labeled or dated.One (1) container of pancake batter without a use by date.One (1) blue bowl with an unknown food, without a use by date.One (1) container of opened liquid eggs with no open or use by date.One (1) container of raw beef patties on the same shelf as two (2) bags of baked potatoes.One (1) package of english muffins not dated.Ice located in the hand washing sink.The wall and the floor behind the ovens was soiled with debris and grease.The stove drip pan was grossly soiled with old food debris.Both ovens are soiled with grease and debris.The small toaster needed to have the crumbs cleaned out.At 12:51 PM the dish machine temperature was 110 degrees F.At 1:23 PM in the nourishment room there was one (1) container of yogurt not dated.One (1) container of hot [NAME] mix was outdated with a use by date of 09/02/2023.One (1) container of hot [NAME] mix was outdated with a use by date of 02/18/2024.At 2:45 PM this surveyor asked for the dish machine temperature logs for the past six (6) months. Employee #100 stated that the Certified Dietary Manager (CDM) has thrown them away. He did find January and February 2026 logs. They had 108 temperatures recorded under the minimum temperature of 120 degrees F out of 182 total temperatures recorded.Employee #100 also states that they have never had a three compartment sink log for temperatures and sanitizer.Employee #63 stated he does not use a dish machine temperature log.Employee # 55 stated it should be in the office.Employee #67 stated it has been a while since I have seen a dish machine temp log.Employee #78 stated I have never used a dish machine temp log here.At 2:46 PM there was an employee beverage sitting on a cart in the kitchen.

Based on interview and record review, the facility failed to employ kitchen staff with the appropriate credentials. This deficient practice had the potential to affect all of the residents receiving meals in the facility. Facility Census: 56.Findings include:03/04/2026 2:49 PM Dietary employee #28, #56 and #78 did not have their food handler card after 30 days of employment, as per [NAME] Virginia code 16-2-16. Employee #100 gave this surveyor a copy of the job description for the three employees in the kitchen that did not have their food handler cards during the beginning of the survey process. The job description states the following: assists in preparation of meal services and servingassist cook in setting up and covering dessertspour and cover beveragesattend and stir foods during the cooking process to prevent burningrelieve the cook of duties such as preparing fruits and vegetables and making toast and beveragescomplete annual state mandated training requirementsobtain food safety certificationhave skills specific to preparing meals for geriatric residents are requiredthe employee is regularly required to stand while preparing food and plating foodtransferring food to serving containers and preparing recipesreach with hand and arms while transferring food to serving containersobtaining and manipulating ingredients or food itemsthe employee is frequently required to taste and smell food when it is being prepared and prior to it being served to ensure that it is pleasing, and to determine the freshness of ingredients and produce being usedthe employee must frequently lift and or move between 10 and 50 pounds of recipe ingredients, frozen meats and foodsdepth perception for cooking on stovetops and in ovens and when plating food in the unit kitchens, and ability to adjust focus when obtaining food from the main kitchen, preparing food, and using kitchen equipment

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 titled Hand Hygiene with implementation date 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. He delivered meal trays to Residents #47, R #27, #22, and #38. Dietary Worker #62 was noted to touch the residents' overbed tables, as well as items on their tables. However, he did not perform hand hygiene between the tray passes. On 03/03/26 at 4:49 PM, Dietary Worker #62 confirmed he hadn't used hand hygiene between tray passes but stated he would start doing so. b) Resident hand hygiene On 03/03/26 beginning at 4:42 PM and continuing through 5:27 PM, Dietary Worker #62 and Nurse Aid (NA) #87 were observed delivering meal trays to [NAME] Hallway residents dining in their rooms. Residents were not offered hand hygiene. On 03/03/26 at 4:49 PM, Dietary Worker #62 was asked about resident hand hygiene before meals. He stated, I don't know about that. On 03/03/26 at 5:29 PM, NA #87 acknowledged resident hand hygiene had not been performed before the meal. She stated the facility had hand wipes to use for resident hand hygiene, but these had not been used tonight.

Based on resident interview, observation, and staff interview, the faciltiy failed to ensure resident dignity during dining. The facility failed to ensure roommates and tablemates in the dining room received their meal trays at the same time. These were random opportunities for discovery. Resident Identifiers: #27, #55, #15, #54, #40, #31, #50, #13, and #43. Facility Census: 56. Findings included: a) Residents who dined in their rooms During the survey resident council meeting on 03/02/26 at 1:00 PM, residents were asked about their dining experiences. The residents reported that roommates did not receive their meal trays at the same time when they dined in their rooms. On 03/02/26, the following observations were made of residents dining in their rooms: Resident #27 received a dinner tray at 4:46 PM. Resident #27's roommate, Resident #55, received a dinner tray at 5:01 PM. After Resident #27 received a tray, Resident #55 was observed asking a staff member where her tray was. Resident #15 received a dinner tray at 4:55 PM. Resident #15's roommate, Resident #54, received a dinner tray at 5:27 PM. On 03/02/26 at 5:27 PM, Dietary Worker #62 was asked why roommates did not receive their meal trays at the same time. Dietary Worker #62 stated residents received their trays based on when their meal orders were obtained by Nurse Aides. He stated the meal orders were then filled and delivered to residents in the order received by the kitchen. On 03/02/26 at 5:40 PM , the Administrator stated the facility had an open dining policy. He stated the residents' meal orders were taken by Nurse Aides using computer tablets which transmit the orders to the kitchen. The meals were then served according to when the orders were taken which lead to different meal service times for roommates dining in their rooms. b) Dining room On 03/03/2026 at 3:50 PM, an observation of the dinner service was completed. All residents were sitting at the table at the same time. At this time, all five (5) residents placed their orders for dinner. The continued observation found the residents were served at different times. The following are the times the residents actually received their dinner orders: --Resident #40 4:15 PM --Resident #31 4:20 PM --Resident #50 4:21 PM --Resident #13 4:22 PM --Resident #43 4:26 PM There was 11 minutes between the 1st resident served and the last resident served. On 03/03/26 at 5:30 PM , the Administrator did confirm if the residents' meal orders were taken at the same time, then there should not have been a delay in getting all residents served.

Based on resident interviews, record review, and staff interviews, the facility failed to develop/implement a care plan for resident #2 regarding their role as Resident Council President. The facility also failed to follow interventions for Resident #10's falls. This finding was true for one (1) of 14 resident care plans reviewed during the long term care survey process. Resident identifiers: #2, #10. Facility census: 56a)Resident #2During an interview with Resident #2 on 02/03/26 at 1:20 PM she revealed she was the Resident Council President. During the interview, Resident #2 expressed concern about not having enough evening activities. She stated she holds a weekly reading group at 6:00 PM, but some residents would enjoy crafting and games such as Bingo in the evenings. Record review completed on 02/03/24 of Resident #2's care plan revealed an intervention stating the following (Residents name here) Resident #2 serves as Resident Council [NAME] President as of February 2022.During an interview with the facility's Activity Director on 02/04/26 at 2:30 PM she stated that Resident #2 is care planned as the President of Resident Council. When shown the care plan she stated, I don't understand; I thought I changed it. This confirmed that Resident #2's care plan was not updated to reflect her being President of the Resident Council. b) Resident #10During record review on 02/04/25 the following fall interventions was on the residents person centered care plan: Bilateral Hip protectors when in bed Call don't fall sign in room within view for reminder not to self transfer r/t confusionand poor memory. Fall mat to right side of bed for safety d/t hx of fallingAn observation on 03/04/26 at 11:00 AM of resident #10 While in bed revealed the fall mat was placed on the left side of the bed, there was no sign hanging in the room stating Call don't fall. During an Interview on 03/04/26 at 11:15 AM with Licensed Practical Nurse (LPN) #35 who confirmed the fall mat should be on the right side of the bed and the sign stating call don't fall was not hanging in the room, at this time LPN #35 also checked Resident #2 and confirmed that she was not wearing hip protectors.

Based on observation, record review, resident interviews, and staff interviews, the facility failed to ensure the ongoing activity program met the interests and psychosocial needs of residents by a) failing to provide sufficient evening activities desired by residents, b) listing hydration cart services on the activity calendar as an activity, and c) failing to provide sensory stimulation programming for lower-functioning residents. These failures demonstrate the facility did not ensure residents were provided person-centered activities designed to meet individual interests, preferences, and functional abilities. This deficient practice had the potential to affect all residents residing in the facility.Resident identifiers: #7, #10, #13, #14, #18, #24, #32, and #48 Facility census: 56.Findings Include:Review of the facility's activity program, resident council concerns, and activity calendars for January through March 2026 identified concerns related to the variety, appropriateness, and availability of activities for residents with differing interests and functional levels as evidenced by the following:a) Evening ActivitiesResidents #2, #7, #10, #13, #14, #18, #24, #32, #48, and #58 reported a lack of meaningful evening activities.On 03/02/26 at 3:13 PM, Resident #7 stated, I go to bed at 5 because there is nothing else to do. They leave games out but that don't mean nothing, we need help.During an interview on 03/02/26 at 1:20 PM, Resident #58 stated, When we have bingo sometimes we don't get to play the full hour because they have to get their work done to leave at 4. Resident #58 further stated, Sometimes we have reading in the evening with Resident #2. It would be nice to have games or other group activities in the evenings.During the Resident Council Meeting on 03/03/26 at 2:00 PM, activity concerns were discussed. Residents #2, #7, #10, #13, #14, #18, #24, #32, #48, and #58 agreed to the following concerns:Bingo is often only played for approximately 40 minutes instead of the scheduled hourNot enough activities are offered, including no shopping trips since OctoberLimited evening activities, consisting primarily of a resident-led reading groupA pastor provides a social twice per month, and church is held once per monthDuring the Resident Council meeting, Residents #2, #7, #50, and #48 stated these concerns had previously been brought to staff attention but no follow-through occurred.Record review on 03/04/26 of the January, February, and March Activity Program Calendars revealed:Craft activities: 11Games: 48Evening activities: 10 (all listed as reading groups)During an interview on 03/04/26 at approximately 3:00 PM, the Activities Director (AD) was asked about the limited evening activities and the activity calendar. When asked how the hydration cart listed daily at 1:00 PM qualified as an activity, the AD stated, They told me I had to put that on there. confirming the hydration cart itself is not an activity. When asked about the limited evening activities, the AD stated, The regulations do not say how many evening activities I have to have. I have worked as the AD here for four years and have not been asked for all of this before. Surveyors confirmed there is no specific required number of evening activities, however activity programming must meet the interests and needs of each resident, and multiple residents expressed interest in additional evening activities beyond those currently offered. The AD stated the April calendar would include more evening activities. b) Hydration Cart Listed as an ActivityRecord review on 03/04/26 of the January, February, and March Activity Program Calendars revealed Hydration Cart was listed daily at 1:00 PM as an activity.During an interview with the Activities Director on 03/04/26 at 3:00 PM, when asked how the hydration cart constituted an activity, the AD stated, They told me I had to put that on there.Providing hydration is a clinical service intended to meet residents' nutritional and hydration needs and does not constitute a recreational or interest-based activity. Activities must support residents' physical, mental, and psychosocial well-being through interest-based engagement, and hydration services alone do not meet the criteria for an activity. c) Sensory Stimulation Activities for Low-Functioning ResidentsRecord review revealed Resident #10 had a BIMS score of 99, indicating the resident does not have cognitive capacity.Observations of Resident #10 were as follows;On 03/02/26 at 11:50 AM: Resident observed sitting in the activity room with the television off and crying out. Surveyor was unable to understand what the resident was vocalizing. No staff intervened. An activity assistant walked past the resident without interaction.On03/02/26 at 2:38 PM: Resident observed in the activity room moving in the wheelchair and appearing agitated, stating she was looking for her husband and family to pick her up and stating he worked all night. No activity engagement was observed.On 03/02/26 at 4:01 PM: Resident remained in the activity room asleep with no activity staff interaction observed.On 03/03/26 at 10:45 AM: Resident again observed asleep in the activity room with no activity staff interaction observed.Record review on 03/04/26 at 10:36 AM of Resident #10's Activity Care Plan indicated the resident:Has some interest in scheduled activitiesShould be encouraged to attend two or more activities dailyEnjoys movies, puzzles, crossword and word search puzzles, country and gospel musicShould be invited and encouraged to participate in activities~Focus (Resident #10's name here), as the resident prefers to be called, has some interest in scheduled activities at times preferring independent activities. Date Initiated: 12/07/2022 Created by: Revision on: 01/07/2026 Revision ~Goal (Resident #10's name here) will self-initiate independent activities daily through next review. Date Initiated: 12/07/2022 Revision on: 01/07/2026 Revision by: Target Date: 03/26/2026 Encourage 2 or more scheduled activities daily through the next review. Date Initiated: 12/28/2022 Created b ~Interventions Assist in tuning tv as needed; enjoys news, sports, soaps, movies Date Initiated: 12/07/2022 Revision on: 12/07/2022 (Resident #10's name here) enjoys comedy, drama, musical movies, crossword, word search and word search puzzles, country and gospel music. Date Initiated: 12/07/2022 Revision on: 12/07/2022 Revision by: [NAME] (Resident #10's name here) is Presbyterian; advise of facility services Date Initiated: 12/07/2022 Revision on: 12/07/2022 Ensure resident is wearing her glasses or contacts as needed during activities ActivitiesDate Initiated: 05/24/2023 Introduce to other residents with similar interests, abilities, and background Date Initiated: 12/28/2022 Invite and encourage resident to participate in activities Date Initiated: 12/28/2022 Offer materials for independent activities; word search and crossword puzzles Date Initiated: 12/28/2022 Revision on: 12/28/2022 Provide with a monthly activities calendar Date Initiated: 12/07/2022 Created by: [NAME] (Activities Director)During an interview on 03/04/26 at 2:45 PM, the Activities Director stated sensory stimulation activities were not offered because residents refused them. When asked how residents who were low functioning or unable to communicate could refuse sensory activities, the AD was unable to provide clarification.Regarding Resident #10, the AD stated the resident's daughter did not want the resident to participate in sensory activities. When asked to provide documentation of this request in the resident's medical record, no documentation was foundResidents with cognitive impairment require individualized and sensory-based activity approaches to support engagement and reduce distress behaviors. The facility failed to implement such programming for Resident #10.

Based on record review, observation and staff interview the facility failed to provide an environment free from accident hazzards. this failed practice was found true for one (1) of one (1) residents reviewed for falls during the Long term Care Survey pricess. Resident identifier: #2 Facility census: 56 Findings include:Record review completed on 03/04/2026 at 10:19 AM revealed Resident #10 had falls on the following dates;11/18/25 1:05AM12/25/25 2:50 PM12/31/25 7:29PM1/14/26 12:37PM2/6/26 4:27 AM Further record review on 02/04/25 the following fall interventions was on the residents person centered care plan: Bilateral Hip protectors when in bed Call don't fall sign in room within view for reminder not to self transfer r/t confusionand poor memory. Fall mat to right side of bed for safety d/t hx of fallingAn observation on 03/04/26 at 11:00 AM of resident #10 While in bed revealed the fall mat was placed on the left side of the bed, there was no sign hanging in the room stating Call don't fall. During an Interview on 03/04/26 at 11:15 AM with Licensed Practical Nurse (LPN) #35 who confirmed the fall mat should be on the right side of the bed and the sign stating call don't fall was not hanging in the room, at this time LPN #35 also checked Resident #2 and confirmed that she was not wearing hip protectors.

Based on observation and staff interview, the facility failed to ensure a medication error rate of less than five (5) percent (%). Three (3) medication errors were made during 25 medication opportunities to make an error rate of 12%. Resident Identifier: #9. Facility Census: 56. Findings included:a) Resident #9 On 03/04/26 at 9:24 AM, Licensed Practical Nurse (LPN) #41 was observed giving morning medications to Resident #9. LPN #41 administered the following medications to the resident: - Ferrous sulfate, 325 milligrams (mg)- Mirtazapine, 15 mg- Rivastigmine tartrate, 1.5 mg LPN #41 had dispensed the pills from a pill packet containing all three (3) pills. Review of Resident #9's physician's orders showed the resident's morning medications were as follows: - Losartan potassium, 50 mg, in the morning for hypertension - Metoprolol tartrate, 25 mg, in the morning for hypertension - Ferrous sulfate, 325 mg, two (2) times a day for supplementation due to amenia - Rivastigmine tartrate, 1.5 mg, two times a day for dementia Mirtazapine, 15 mg, was ordered at bedtime for depression and poor appetite. On 03/04/2026 at 11:33 AM, LPN #41 was questioned regarding the medications she dispensed to Resident #9. She realized the packet she took the pills from was labeled 03/04/26 at 7:00 PM. LPN #41 confirmed she had administered Mirtazapine at the wrong time because it was ordered to be given at bedtime. She also confirmed she had omitted Losartan potassium and Metoprolol tartrate, which were scheduled to be given to the resident in the morning. No further information was provided through the completion of the survey process.

Based on observation, record review, and staff interview, the facility failed to ensure the posted daily nurse staffing information was accurate by not havinf total hours worked on the staff posting. This was found true for all staff postings reviewed for the past year. Facility census: 56Findings include:An observation on 03/02/26 at 12:04 PM showed the staff posting did not have the total hours worked posted.]Record review on 03/02/26 for staff postings for the past year revealed none of the staff posting contained total hours worked. During an interview on 03/02/26 at 1:04 PM with the Director of Nursing (DON) who questioned what's missing? When informed of the requirement for staff posting the DON stated Ok, i will get working on fixing this now. confirming the staff postings did not contain the required information.

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 PM, the Director of Nursing (DON) confirmed the physician had not evaluated Resident #2 for bleeding on 03/02/26. She stated the physician had to leave and was planning on seeing the resident next week. She also confirmed there was no documentation the physician had been notified of the resident's bleeding on 02/28/26, although she believes the nurse would have done so. The DON stated the physician had given orders on 03/04/26 for a complete blood count to be obtained the next morning to evaluate the resident's hemoglobin level. She stated a urine culture could not be obtained at this time because the resident was on antibiotics for a skin infection. No further information was provided through the completion of the survey process.

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 discard the vial and order a new one.

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 the vegetable soup that could have been allergic to something in the soup. On 3/3/26 the facility did not follow their menu for lunch. The menu showed the following: Corn chowder Ham salad sandwich Creamy cucumber salad Fruit They served: Vegetable soup Ham Salad sandwich Tater tots Fruit 03/03/2026 at 2:18 PM Interview with employee #100 about the menu being changed. He stated the corn did not come in and the cucumbers were sent back due to not being fresh. We do not use a menu substitution log. b) 03/03/2026 10:48 AM Resident #35 states the food sucks. c) 03/03/2026 at 1:00 PM Resident Council Meeting The residents stated the following: The menus are not followed. We do not receive what is on our ticket. We never know what the soup of the day is going to be. We do not get served together. We are missing items on our tray. During a resident council meeting on 03/03/26 at 1:00 PM, the resident council members stated menus were not followed and residents did not always receive the items they requested on their meal trays.

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 Type II Diabetes Mellitus. Hold for blood glucose less than 150. Call MD (doctor) if BS (blood sugar) is above 400. Review of the April 2024, May 2024, June 2024 and July 2024 Medication Administration Records (MARs) indicated Resident #56's blood sugar level was over 400 the following nine (9) times without notification to his attending physician: -04/26/24 at 9:00 PM, Blood Sugar 412 -05/05/24 at 4:00 PM, Blood Sugar 438 -05/05/24 at 9:00 PM, Blood Sugar 529 -05/07/24 at 4:00 PM, Blood Sugar 421 -05/08/24 at 4:00 PM, Blood Sugar 456 -05/09/24 at 9:00 PM, Blood Sugar 479 -05/12/24 at 4:00 PM, Blood Sugar 462 -05/14/24 at 9:00 PM, Blood Sugar 409 -07/12/24 at 9:00 PM, Blood Sugar 447 During an interview on 08/07/24 at 4:00 PM, the Director of Nursing (DON) stated the facility was unable to locate evidence the physician was notified of the above-mentioned blood sugar levels. b) Resident #3 A record review, completed on 08/06/24 at 11:01 AM, revealed the following discrepancy: -The code status listed on the profile page of the electronic medical record stated: Full Code - Limited Additional Interventions-12/10/18 -The Physician Orders for Scope of Treatment (POST) form, signed 03/21/24, stated: FULL Code / FULL Treatment During an interview on 08/07/24 at 12:00 PM, the Director of Nursing (DON) reported the facility had failed to change Resident #3's code status to Full Code / Full Treatment following the 03/21/24 updated POST form being signed.

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 between the tiles of the shower room walls. In addition, the air conditioning vent grills in the ceiling were coated with a thick, furry layer, of lint and debris. During an interview with the Environmental Services Supervisor #53 on 08/06/24 at 2:28 PM, she stated they power wash the walls, but confirmed the shower room walls, and air conditioning vents, were dirty and needed to be cleaned. 50795 b) [NAME] wing shower room Inspection of the [NAME] wing shower room on 08/06/24 02:10 PM revealed a black substance between the tiles of the shower room walls. In addition, the air conditioning vent grills in the ceiling were coated with a thick, furry layer, of lint and debris. During an interview with the Environmental Services Supervisor #53 on 08/06/24 at 2:28 PM, she stated they power wash the walls, but confirmed that the shower room walls, and air conditioning vents, were dirty and needed to be cleaned.

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 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.

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 regarding showers, she emphasized the difficulty of getting the residents showered, highlighting the constraint of having only one shower room on each wing. LPN #30, on 08/07/24 at 12:33 PM, stated that she had informed Clinical Operations Specialist #6 that Resident #25 requested three showers per week. On 08/08/24 at 2:58 PM, Resident #25 approached this surveyor near the office, and Clinical Operations Specialist #6 was within hearing range. Resident #25 asked, Am I going to get my three showers from now on? The resident was reassured that the facility had been notified of her request. b) Resident #40 In an interview with Resident #40 on 08/06/24 at 3:19 PM, she disclosed that she is Catholic. She mentioned that she wakes up around 4:30 AM every morning to watch church services on TV. She also stated that she says her rosary, and would like assistance getting out of bed and being cleaned by 7:00 AM. However, she mentioned that her requests had been ignored by the Nursing Assistant (NA). Additionally, she mentioned that a woman representing the State had visited her a few weeks ago, to whom she had also expressed her request, but nothing had come of it. Record review revealed a nursing note dated 8/6/2024 at 12:56 PM which stated: Resident is alert & oriented person place time intermittently confused forgetful On 08/06/24 at 04:11 PM, during an interview with LPN #60, she mentioned that Resident #40 is often confused, but can still respond to questions. The LPN also noted that the staff were uncertain about the resident's needs due to her frequent changes of mind.

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 grievances for a period of three (3) years from the date the grievance decision is issued. b) Resident Council On 08/08/24 at 12:00 PM during an interview with Resident Council, they stated the facility did not respond to grievances or help with resolution. Continued interview revealed Resident #55 stating she had complained about her roommates Husband coming late at night and stays most of the night. She continued to say nothing was ever done. Subsequent interview with Resident Council members stating Resident #12 and her husband is loud during his visit and keep them awake. They stated they complain to the nurses at night, and no one ever says anything to them. During an interview with the Social Worker on 08/08/24 at 12:50 PM, she stated Resident #55 did come to her with a grievance about leaving the facility because she did not like having a semiprivate room. She continued to say Resident #55 told her at time, her roommate's husband comes in late at night and is in her room. The Social Worker stated she thought Resident #55 just wanted to move back to the community. She continued to say, she did not file a grievance about Resident #12's husband late visitation and being in the resident #55's room late at night.