Washington Senior Living

Based on Observation, Interview and Record Review, the facility failed to document an appropriate diagnosis, provide justification for a failed gradual dose reduction (GDR), and identify and monitor targeted behaviors to warrant the use of Seroquel (antipsychotic medication) and for one of one resident (R39) reviewed for antipsychotic medications in the sample of 48.Findings include:The facility's Psychopharmacologic Drug Use Procedure policy (undated) documents To assure that appropriate monitoring is provided to residents receiving psychopharmacologic drugs, that the lowest possible dose necessary for the benefit of the resident to improve or control mood, mental status and/or behavior is utilized, and to reduce or eliminate the usage of these medications. Residents shall not be given antipsychotic drugs unless antipsychotic drug therapy is necessary to treat a specific or suspected condition as diagnosed and documented in the clinical record or to rule out the possibility of one of the conditions listed in guidelines of recognized external review agencies. Documentation of…

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 interview, the facility failed to obtain a level II PASRR (Pre-admission Screening and Resident Review) for three of five residents (R3, R55, and R69) reviewed for pre-admission screenings in the sample of 48.Findings include:1. R3's admission Record, dated 3/10/26, documents R3 admitted to the facility on [DATE]. This same admission Record documents a medical diagnosis of Bipolar Disorder with an onset date of 4/21/2022.R3's Minimum Data Set (MDS), dated [DATE], documents R3's BIMS (Brief Interview for Mental Status) of 14, indicating R3 is cognitively intact.R3's OBRA-I (Omnibus Budget Reconciliation Act-I) Initial Screen, dated 9/4/20, documents, in Part III: Reasonable Suspicion to Suspect a Mental Illness, under 4. There are other indicators of mental illness in Part III: Reasonable Basis to Suspect a Mental Illiness: 'Yes. This same document later lists a medical diagnosis of Depression.R3's Medical Record was reviewed and there was no evidence of a PASRR (Pre-admission Screening…

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 Observation, Interview and Record Review, the facility failed to ensure a resident's independent smoking assessment was accurate and smoking materials were not kept in the resident's possession when not in use, and ensure a dependent resident was provided assistance of two staff members during a mechanical lift transfer, for two of four residents (R46, R55) reviewed for accidents in the sample of 48.Findings include: The facility's Resident Smoking policy, dated 12/202, documents All residents who will be assessed by the interdisciplinary team to determine if the individual is appropriate for independent smoking. It is recommended that independent smokers store their smoking materials at the nursing station for the safety of others. If they choose not to then they should keep them secure at all times. The facility's Safe Lifting and Movement of Residents Policy, dated September 2008, documents in part, Policy Statement: In order to protect the safety and well-being of staff and residents, and to promote…

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 observation, interview, and record review, the facility failed to ensure indwelling urinary catheter tubing and the collection bag were positioned below the level of the bladder and remained off the floor for one of two residents (R49) reviewed for indwelling urinary catheters in the sample of 48.Findings include:The facility's Catheter Care, Urinary Policy, dated September 2005, documents in part, The purpose of this procedure is to prevent infection of the resident's urinary tract. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Be sure the catheter tubing and drainage bag are kept off the floor.R49's admission Record, dated 3/10/26, documents R49 was admitted to the facility on [DATE] with medical diagnoses to include but not limited to: Unspecified Severe Protein-Calorie Malnutrition, Active Primary Progressive Multiple Sclerosis, Neuromuscular Dysfunction of…

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, interview, and record review the facility failed to ensure oxygen tubing/humidification and a nebulizer mask, canister, and tubing was dated, changed every seven days, and placed in a bag when not in use and ensure an order was in place for oxygen for three of three residents (R27, R50, and R78) reviewed for respiratory care in a sample of 48.Findings include: The facilities Oral Inhalation Administration, dated 11/4/14, documents, Nebulizer- When equipment is completely dry, store it in a plastic bag with the resident's name and the date on it. Change equipment and tubing every seven days. The facilities Oxygen Administration Policy, dated 3/2004, documents Prepare: The purpose of this procedure is to provide guidelines for safe oxygen administration. Steps in the procedure: 18. Make sure the oxygen humidifier jar is labeled properly. 1.R27's Order Summary Report documents a Physician order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3)MG (milligram)/3ML (milliliter) one vial inhalation every six hours as needed. On 3/9/26 at 9:42 AM R27's nebulizer…

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 observation, interview and record review the facility failed to properly store urine-soiled resident clothing in a bag during incontinence care for one resident (R14) and failed to follow Contact Isolation Precautions and don appropriate PPE/Personal Protective Equipment before manipulating an indwelling urinary catheter collection bag for one resident (R49) of 18 residents reviewed for infection control procedures in the sample of 48 residents.Findings include:1. After several attempts, the facility was unable to provide an Incontinence Care policy. The facility's Infection Prevention and Control Manual Transmission-Based Precautions Policy, dated 2020, documents in part, The purpose of contact precautions is to prevent transmission of infections that are spread by direct (e.g., person-to-person) or indirect contact with the resident or environment. Contact precautions require the use of Personal Protective Equipment (PPE), including a gown and gloves upon entering the room or making contact with the…

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, interview, and record review the facility failed to educate residents on what a grievance is, provide grievance forms, and provide a clear and noticeable destination for grievances to be submitted. This failure has the potential to affect all 63 residents who reside in the facility. Findings Include:The Filing Grievances/Complaints policy dated 12/2004 documents Our facility will assist residents, their representatives (sponsors), other interested family members, or resident advocates in filing grievances or complaints when such requests are made. The Ombudsman Program Residents' Rights Booklet (undated) documents Your personal property rights. You have the right to keep and wear your own clothing. Your facility must try to keep your property from being lost or stolen. If your property is missing, the facility must try to find it.The Resident Council meeting minutes dated 7/8/2025 documents, R11, R28, R38, R48, and R64 all confirmed they did not know what a grievance was or how to file a grievance.The facility census sheet dated 8/18/2025 documents 63 residents…

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 notify the Residents Family/Representative promptly of a change of condition for one of three residents (R1) reviewed for injury of unknown origin in the sample of three. Findings include: The Notification of Resident Change in Condition Policy (undated) documents Policy: It is the policy of this facility to promptly notify the resident, their legal representative(s) and attending physician of changes in the resident's health condition. Policy Specifications: To establish guidelines for assuring residents, their legal representatives and attending physicians are informed of changes in the resident's condition. Responsibility: Director of Nursing and Licensed Nurses. Standards: 1. A licensed nurse shall promptly inform the resident, consults with the resident's physician and if known, notify the residents legal representative or an interested family member of: a. An accident involving the resident in which there is a potential for an actual injury which could require nursing or medical intervention. b. A significant change…

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 promote an environment free of inappropriate staff behavior and failed to provide respect and dignity for residents. This failure has the potential to affect all 79 residents residing in the Facility. Findings include: The Facility Resident Census Roster, dated 6/19/25, documents 79 Residents residing in the Facility. The Facility Statement of Resident Rights, undated, documents: the Resident has a right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the Facility; must treat each Resident with respect and dignity and care for each Resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each Resident's individuality; protect and promote the rights of the Resident; and has the right to be treated with respect and dignity; have a right to a safe and homelike environment including but not limited to treatment and supports for daily living safely; and a safe comfortable and homelike…

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 conduct a thorough abuse investigation for two of four residents (R1 and R2) reviewed for abuse and failed to protect residents from further potential abuse. This failure has the potential to affect all 79 Residents residing in the Facility. Findings include: The Facility Abuse Prevention Program Policy, dated 10/2022, documents: the Facility must affirm the right of our residents to be free from abuse; prohibits abuse; facility has established a resident sensitive and resident secure environment; assures that the Facility is doing all that is within its control to prevent occurrences of abuse; the Facility will establish an environment that promotes resident sensitivity and resident security; identify occurrences and patterns of potential mistreatment; immediately protect residents involved in identified reports of possible abuse; implement systems to promptly and aggressively investigate all reports and allegations of abuse and make necessary changes to prevent future occurrences; filing accurate and timely investigation…

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 notify Resident Physicians and Resident Representatives for an Abuse incident for two of four Residents (R1 and R2) reviewed for notification of change in a sample of four. Findings include: The Facility Abuse Prevention Program Policy, dated 10/2022, documents: the Facility must affirm the right of our residents to be free from abuse; prohibits abuse; facility has established a resident sensitive and resident secure environment; assures that the Facility is doing all that is within its control to prevent occurrences of abuse; implement systems to promptly and aggressively investigate all reports and allegations of abuse abuse is defined as physical or mental injury inflicted upon a resident other than by accidental means and is the willful infliction of injury resulting in physical harm, pain or mental anguish, physical abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment; verbal abuse is a gestured language that willfully includes disparaging and derogatory terms to…

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 protect one of four Residents (R1) from a Resident Perpetrator (R2) reviewed for abuse in the sample of four. Findings include: The Facility Abuse Prevention Program Policy, dated 10/2022, documents: the Facility must affirm the right of our residents to be free from abuse; prohibits abuse; facility has established a resident sensitive and resident secure environment; assures that the Facility is doing all that is within its control to prevent occurrences of abuse; the Facility will establish an environment that promotes resident sensitivity and resident security; identify occurrences and patterns of potential mistreatment; immediately protect residents involved in identified reports of possible abuse; implement systems to promptly and aggressively investigate all reports and allegations of abuse and make necessary changes to prevent future occurrences; facility is committed to protecting residents from abuse from anyone including other residents; abuse is defined as physical or mental injury inflicted upon a resident other…

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 report an allegation of abuse to the local State Agency for two of four residents (R1and R2) reviewed for Abuse in a sample of four. Findings include: The Facility Abuse Prevention Program Policy, dated 10/2022, documents: the Facility must affirm the right of our residents to be free from abuse; prohibits abuse; facility has established a resident sensitive and resident secure environment; assures that the Facility is doing all that is within its control to prevent occurrences of abuse; the Facility will identify occurrences and patterns of potential mistreatment; immediately protect residents involved in identified reports of possible abuse; implement systems to promptly and aggressively investigate all reports and allegations of abuse and make necessary changes to prevent future occurrences; filing accurate and timely investigation reports; abuse is defined as physical or mental injury inflicted upon a resident other than by accidental means and is the willful infliction of injury resulting in physical harm, pain 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 interview and record review the facility failed to immediately report an allegation of misappropriation of funds to the State Agency and the administrator and immediately report an allegation of sexual abuse to the State Agency one of three residents (R1) reviewed for Abuse in the sample of three. Findings include: The facility's Abuse Prevention Program policy dated 10/2022 documents, Internal Reporting Requirements and Identification of Allegations: Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator, or to a compliance hotline or compliance officer. External Reporting. 1. Initial Reporting of Allegations: When an allegation of abuse, exploitation, neglect, mistreatment, or misappropriation of resident property has been made, the administrator, or designee shall notify Department of Public Health's…

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 investigate an allegation of abuse for one of three residents (R1) reviewed for investigation of abuse in the sample of three. Findings include: The facility's Abuse Prevention Program policy dated 10/2022 documents, All incident will be documents, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of resident property occurred, was alleged or suspected. Any incident or allegation involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property will result in an investigation. On 5-16-25 at 10:50 AM V17 (CNA) stated, Last Sunday while I was working second shift, (R1) told me that a staff member took (R1's) money to get (R1) food and never brought back the money or the food. (R1) did not know who took her money and did not describe the staff member. I did not report this to a nurse or the Administrator (V1). On 5-16-25 at 11:50 AM V1 stated, An investigation has not been done regarding (R1) alleging a staff member stole her money. The facility's Abuse Investigations…

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, interview, and record review the facility failed to ensure mechanical lift transfers were safely completed for one (R2) of three residents reviewed for falls in the sample of nine. Findings include: The facility Safe Lifting and Movement of Residents policy and procedure, dated August 2008, documents Mechanical lifting devices shall be used for any resident needing a two person assist. The facility Using a Portable Lifting Machine policy and procedure, dated August 2008, documents The portable lift should be used by two staff members. The facility fall log documents R2 had a change in center of gravity on 4/12/25 at 11:50 AM. The Fall Investigation for R2, dated 4/12/25 at 11:50 AM documents V14 CNA (Certified Nursing Assistant) was transferring R2 with a mechanical lift and during maneuvering R2 in the mechanical lift sling into R2's high back reclining wheelchair a change in center of gravity occurred causing (mechanical) lift to tip over. V14 CNA yelled for help, V15 LPN (Licensed Practical Nurse) overheard V14 CNA yelling for help and observed R2 and V14…

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, interview, and record review the facility failed to report a potential allegation of abuse to the State Agency for one (R1) of three residents reviewed for abuse in the sample of eight. Findings include: The facility's undated Abuse Prevention Training Program - Protocol documents Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The objective of the Abuse Prevention Program is to comply with the seven-step approach to abuse and neglect detection and prevention. Employees are required to report any allegation of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator. An initial report to the State licensing agency (Named Agency), shall be made immediately after the resident has been assessed and the alleged perpetrator has been removed. This same policy also documents…

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, interview, and record review the facility failed to identify and investigate a potential allegation of abuse for one (R1) of three residents reviewed for abuse in the sample of eight. Findings include: The facility's undated Abuse Prevention Training Program - Protocol documents Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The objective of the Abuse Prevention Program is to comply with the seven-step approach to abuse and neglect detection and prevention. The staff, with the physician's input (as needed), will investigate alleged occurrences of abuse and neglect to clarify what happened and identify possible causes. As soon as possible after an allegation of abuse, neglect, mistreatment, misappropriation of resident property, or exploitation, the administrator or designee will initiate an investigation into the allegation which may include the following elements: Interviewing all persons who may have knowledge of the alleged incident, including, but not…

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 investigate thoroughly and protect (by not removing the male CNA/Certified Nurse Aid) pending an investigation for one (R4) of three residents reviewed for abuse in a sample of seven. Findings include: Facility Abuse and Neglect Policy, revised August 2008, documents, The staff will investigate alleged occurrences of abuse to clarify what happened and identify possible causes. The facility will remove any alleged perpetrators of abuse from any further contact with residents pending an investigation. If the alleged perpetrator is an employee, the employee will be sent home and advised not to return to work until further notice. That employee shall be immediately suspended without pay, not having any further resident contact, pending the outcome of the investigation. Interview all persons who may have knowledge of the incident. Facility final Reportable Event submitted to the state agency by V1 Administrator, dated 1/16/25, documents, Event occurred on 1/11/25 at 7PM, and (R4) has Alzheimer's disease and demonstrates…

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, interview and record review the facility failed to provide daily sanitation of the facility and resident rooms during outbreaks of respiratory and gastrointestinal viruses. This failure has the potential to affect all 76 residents in the facility. Findings include: Resident Room Roster dated 2/11/25 indicates there were 76 residents in the facility on that date. On 2/11/25 a tracking document presented by V3, ICP (Infection Control Preventionist) indicated between 1/25/25 and 2/3/25 23 residents were identified as having symptoms of nausea/vomiting/diarrhea and two residents (R4 and R8) diagnosed with Norovirus; nine residents identified as having respiratory symptoms including shortness of breath/cough with six residents identified positive for Influenza A and five residents positive for RSV (Respiratory Syncytial Virus). On 2/11/25 at 12:15pm V8, Housekeeping Manager was assisting R6 to change rooms by packing up R6's belongings. V8 stated, I'm the only housekeeper here right now, there are no other housekeepers in the building. One housekeeper would be…

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, interview, and record review, the facility failed to have a routine cleaning schedule for the kitchen, document or have an expiration date for bread, keep the floor and steamer oven clean, store food off the floor, keep sanitization logs for the dishwasher, and keep freezer/cooler/refrigerator temperature logs. These failures have the potential to affect all 73 residents living in the facility. Findings include: On 12/18/24 at 1:09PM, during the tour of the kitchen there was no cleaning schedule posted for staff, and no cleaning check off sheets for the staff; multiple boxes of food stacked on top of one another in the middle of the freezer on the floor; no sanitization logs posted or able to be provided for the dishwasher; no freezer or cooler/refrigerator temperature logs posted on the freezer or cooler/refrigerator and unable to be provided; eight/8 loaves of bread were on the food storage racks with no delivery date, box, or expiration date on the bread; the kitchen steamer/oven had a build-up of a black sticky substance on the bottom; and the kitchen…

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 have a procedure to reduce the risk of Legionella in the facility's water system. This failure has the potential to affect all 73 residents living in the facility. Findings include: On 12/17/24 at 11:28AM and during the survey through 12/20/24, V3 Maintenance Director was unable to provide any information/documentation on the facility's Legionella procedures, water system, or risk assessment. On 12/17/24 at 11:28 AM, V3 Maintenance Director stated, I do not flush the pipes for Legionella or have a water management plan. What is that? All I do is check temperatures on the hallways weekly for the water temperatures, and I have been here since February 2024. On 12/18/24 at 10:00 AM, V4 IP/Infection Preventionist stated, I don't do anything with Legionella Disease water plan at all, and we have had no residents with Legionella. The Facility Long term care application for Medicare and Medicaid, dated 12/17/24, documents 73 residents currently reside in the facility. Facility Water Management Program, undated, documents It is…

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 maintain documentation of COVID-19 staff vaccinations, screening, offering, or education. This failure has the potential to affect all 73 residents living in the facility. Findings include: Facility COVID-19 Vaccine, effective 1/4/21, documents, The Infection Control Coordinator will maintain surveillance data on COVID-19 vaccine coverage. Surveillance data will be made available to staff as part of educational efforts to improve vaccination rates among employees. On 12/18/24 at 10:00AM and during the survey through 12/20/24, V4 IP/Infection Preventionist was unable to provide any documentation regarding staff COVID-19 vaccinations, screening, offering, or education. On 12/18/24 at 10:00 AM, V4 IP stated, I don't know what staff is fully vaccinated or not for COVID-19. I have not screened, educated, or offered staff the COVID-19 vaccination. The Facility Long term care application for Medicare and Medicaid, dated 12/17/24, documents 73 residents currently reside in the facility.

Based on observation, interview, and record review the facility failed to complete thorough fall investigations for three (R15, R48, and R49) residents of eight residents reviewed for falls in the sample of 25. Findings include: On 12/18/24 at 8:55 am, V1 Administrator stated V2 DON (Director of Nursing) oversees all the resident falls. The falls are discussed in morning meeting, and they come up with interventions and update the care plans. On 12/19/24 at 9:20 am, V2 DON (Director of Nursing) stated about 85 percent of the Nurses the facility uses are from the local Agency Service, so all I have is what is there. V2 DON stated, Details of the fall is what's missing in the (computer system) and that is all the information V2 has regarding resident falls. V2 DON stated falls are discussed in the morning meetings with the IDT (interdisciplinary team), interventions are decided and placed on the resident's care plan at that time. V2 DON confirmed she does not always know the root cause of the resident fall due to lack of documentation from the Nurses. On 12/19/24 at 11:15 am, V1…

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 ensure the required in-service training was completed for Certified Nursing Assistants/CNA. This failure has the potential to affect all 61 residents residing in the facility. Findings include: The Facility Assessment for (named facility), signed and dated 8/8/24, documents, Required in-service training for nurse aides. In-service training must: Be sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year. Include dementia management training and resident abuse prevention training. Address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff. For nurse aids providing services to individuals with cognitive impairments, also address the care of the cognitively impaired. The facility's Certified Nursing Assistant job description, revised October 2020, documents, Staff Development Functions: Attend and participate in facility in-service training programs as…

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, interview, and record review the facility failed to implement their Abuse Prevention Program to protect residents from repeated physical abuse for one (R4) of four residents reviewed for abuse in the sample of six. Findings include: The facility's Abuse Prevention Program policy, dated 10/2022, documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This policy continues to state VI. Protection of Residents. The facility will take steps…

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 report an allegation of resident-to-resident verbal and physical abuse for two (R3 and R4) of four residents reviewed for abuse in a sample of six. Findings include: The facility's Abuse Prevention Program policy, dated 10/2022, documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This policy continues with V. Internal Reporting Requirements and Identification of Allegations: Employees are…

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 investigate a potential allegation of resident-to-resident verbal and physical abuse for two (R3 and R4) of four residents reviewed for abuse in a sample of six. Findings include: The facility's Abuse Prevention Program policy, dated 10/2022, documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This policy continues with Abuse means any physical or mental injury or sexual assault inflicted upon a…

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 a copy of the bed hold policy for residents transferring to the hospital for one (R3) of three residents reviewed for bed holds in the sample of six. Findings Include: The facility's undated Bed Hold Policy documents, There may be instances when a Facility Resident leaves the Facility for medical or therapeutic reasons. If the Resident pays the Facility to hold the bed open, the Facility guarantees availability of a bed on Resident's return to the Facility. In such cases, Facility may be able to re-admit Resident to the same room and bed, but this is not assured. The facility's Transfer and Discharge Policy, dated March 2014, documents, Policy: To assure resident transfers and discharges will be conducted in accordance with residents' rights, physician's orders, and in such a manner as to maintain continuity of care for the resident. This policy continues with Policy Specifications: 4. Relocation rights including bed hold and readmission rights will be maintained in all transfers. R3's clinical record documents that…

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, interview, and record review the facility failed to serve food at a palatable and appetizing temperature. These failures have the potential to affect all 68 residents residing within the facility. Findings include: The facility's Resident Roster dated 6-21-24 documents the facility had 68 residents residing within the facility. The facility's Monitoring Food Temperature for Meal Service policy dated 12-18-18 documents, 1. Prior to serving a meal, food temperatures will be taken and documented for all hot and cold foods to ensure proper serving temperatures. Any food item not found at the correct holding/serving temperatures will not be served but will undergo the appropriate corrective action listed below. 2. Temperature for each food time will be recorded on the Food Temperature Log. Foods that required a corrective action (such as reheating) will have the new temperature recorded with a notation of the corrective action intervention. If the serving/holding temperature of a hot food time is not at 135 degrees F (Fahrenheit) or higher when checked prior to meal…

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 interview, the facility failed to notify a resident's representative of a significant change in condition for 1 of 3 (R1) residents reviewed for Improper Nursing Care. Findings include: The Change in a Resident's Condition or Status policy revised 8/2008 documents Our facility shall promptly notify the resident, his or her representative of change in the resident's medical/mental condition and/or status. 3. Director of Nursing or designee will notify the resident/legal representative when: a. The resident is involved in any accident, incident or unusual occurrences with or without injury. 4. Notification will be made as soon as possible. 5. The Director of Nursing or designee will record in the resident's medical record information relative to change in the resident's medical/mental condition or status. R1 was admitted on [DATE] with the diagnoses of Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety; Anxiety Disorder and Cognitive…

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 allow a resident readmission to the facility; initiate the required Involuntary Discharge Documents which include evidence the resident was a danger to the facility upon his return; and failed to assist the resident in finding an alternate, suitable placement. This affected one resident (R1) of three residents (R3, R4) reviewed for Transfer and Discharge. Findings: The Transfer and Discharge Policy dated 3/14 documents, Policy Specifications: 1. The facility shall permit all residents to remain in the facility and not transfer or discharge except in those circumstances outlined in the Residents Rights and in accordance with state-outlined involuntary relocation procedures. The Involuntary Relocation Policy effective 2014 documents 5. Involuntary relocation or discharges, both within the facility or between facilities, will only occur under the following situations, and will be documented in the resident's record: a. Transfer or discharge is necessary for the resident's welfare and needs which cannot be met in the facility.…

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 and interview the facility failed to offer bedtime snacks to six of 18 residents (R6, R19, R50, R54, R65, R130) reviewed for bedtime snacks in the sample of 27. Findings include: The facility's Fortified Foods, Supplements, and Snacks policy dated 2020 documents, Snacks: Regular food items that are available on the units or can be specified to be served at designated times such as HS (night-time) and generally are not required to be ordered by a physician. The resident's acceptance of the fortified foods, two cal. (calorie) medication pass, and other supplements/snacks is monitored for resident tolerance and acceptance by the dining services manager and registered dietician. Acceptance observational data may be included in a progress notes, care planning summary documentation, or by other members of the interdisciplinary team in designated locations in the medical record such as nursing or therapy notes. 1. R6's Order Summary Report dated 1-24-24 documents R6 has the diagnoses of Dementia and Vitamin Deficiency. R6's Medical Record does not include any…

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 observation, interview, and record review the facility failed to ensure a call light was in reach for three residents (R31, R55, and R280) out of 18 residents reviewed for call lights in the sample 27. Finding include: The Call Light System Policy dated 2/2014, documents, It is the policy of this facility to provide a means of communication to meet the needs of each resident. R31's Current Medical Record documents that R31 was admitted to the facility on [DATE] with diagnosis that included Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-dominant Side, Type 2 Diabetes Mellitus, Anxiety Disorder, and Major Depressive Disorder. R31's Minimum Data Set assessment dated [DATE] documents R31 has a BIMs (Brief Interview of Mental Status) of 13 (cognition intact). On 1/21/24 at 10:10 AM, R31 was sitting in her (reclining wheelchair) in the middle of her room watching television. R31 stated that she was not feeling well and would like to go to bed. R31's call light was clipped to her…

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 and interview the facility failed to obtain a level II PASARR (Pre-admission Screening and Resident Review) evaluation for one of one resident (R6) reviewed for no level II PASARR with the diagnosis of a mental illness in the sample of 27. Findings include: The facility's Pre-admission Documents dated 10-1-2019 documents, Policy: To establish uniform guidelines for all facilities to follow in gathering all required documents prior to admitting residents to the facility. admission will ensure any state and/or federal pre-screening is performed, as required by regulations, prior to admission. Requirements include OBRA (Omnibus Budget Reconciliation Act) Screens, sex offender screening, and a criminal background check. R6's admission Note dated 6-9-23 documents R6 was admitted to the facility from another assisted living facility after being hospitalized for a manic episode. This same note documents R6 has the diagnoses of Paranoid Schizophrenia, Depression, Dementia, and Anxiety. R6's Notice of PASARR Level I Screen Outcome dated 6-9-23 documents R6's Level I…

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 complete and implement gradual dose reductions (GDR) while continuing psychotropic medication for one (R61) of three residents reviewed for psychotropic medications in a sample of 27. Findings include: The facility's undated Medication Regimen Review/MRR Policy documents, Standards: 3. Documentation of the drug review will be made in the resident's medical record by signature of reviewer and date. 4. Specifics regarding the Drug Regimen Review will be documented on a drug regimen review form which includes potential or actual problems, drug interaction or potential adverse drug reactions or any irregularities found and suggestions for laboratory tests. If there are no recommendations, this will be noted. The facility's Antipsychotic Medication Use Policy, dated August 2008, documents, Policy Interpretation and Implementation: 14. The Physician shall respond appropriately by changing or stopping problematic doses or medications, or clearly documenting (based on assessing the situation) why the benefits of the medication…

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, interview and record review the facility failed to wear hairnets while in the kitchen around food and clean dishes. This failure could affect all 76 residents who currently reside in the facility. Findings Include: The Facility's Hair Restraints policy dated 2020 documents Hair restraints shall be worn by all Dining Services staff when in food production areas, dishwashing areas, or when serving food. Hair restrains, hats, and/or beard guards shall be used to prevent hair from contacting exposed food, Facial hair is discouraged. Any facial hair that is longer the eyebrow shall require coverage with a beard guard in the production and dishwashing areas. On 12/20/23 at 8:50 AM V10 (Cook) was standing in the kitchen. V10 did not have a hat, head covering or hair restraint of any sort on. V10 stated I try to always remember to put a hair net on. V10 confirmed that he had served breakfast this morning without his hair net on also. On 12/20/23 at 11:00 AM V9 (Dishwasher) was unloading the dishwasher. V9 had a full beard and did not have on a beard guard. V11 (Dietary…

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, interview and record review, the facility failed to properly store medications for two residents (R13, R14) during a routine medication pass. Findings Include: The Facility's Storage of Medications policy dated 10/27/2014 documents, (This Pharmacy) dispenses medications in containers that meet regulatory requirements, including standards set forth by the United States Pharmacopeia (USP). Medications are kept in these containers. Nurses may not transfer medications from one container to another or return partially used medication to the original containers. All medications dispensed by the pharmacy are stored in the container with the pharmacy label. On 12/20/23 at 9:00 AM V6 (Registered Nurse) opened the top of her medication cart and there was a clear medication cup full of medicines. V6 stated, Those are (R13)'s morning medications, I was going to take them down to him in a little bit. V6 stated, I shouldn't have put the pills in the top of my cart unlabeled, but I do know whose they are. R13's Medication Administration Record for 12/20/23 8:00 AM lists R13's…

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 observation, interview and record review, the facility failed to ensure resident's bed was free from debris and an eating container for one (R4) of three residents reviewed for comfortable living environment in a sample of three. Findings include: The facility's Resident Rights for People in Long Term Care Facilities handbook, undated, documents, You have the right to safety and good care. Your facility must provide services to keep your physical and mental health, and sense of satisfaction. R4's Diagnoses include: Cerebral palsy, ventricular tachycardia, cardiogenic shock, chronic obstructive pulmonary disease, diabetes, amputation of left lower leg, respiratory failure, anxiety disorder, weakness, chronic kidney disease, major depressive disorder. R4's 9/13/23 Progress Note documents: Resident admitted to facility on (Hospice). Tremors noted to bilateral hands and needs assist with meals. R4's Minimum Data Set (MDS), dated [DATE], documents: R4 has a BIMS (Brief Interview of Mental Status) score of…

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 interview and record review, the facility failed to prevent a fall, and failed to provide immediate transfer to emergent medical care for one (R1) of three residents reviewed for accidents/hospital transfers in a sample of three. This failure resulted in R1 being hospitalized with left hip fracture. Findings include: The facility's Falls - Clinical Protocol Policy, dated 8/2008, documents: 3.a. Risk factors for subsequent falling include lightheadedness or dizziness, multiple medications, musculoskeletal abnormalities, peripheral neuropathy, gait and balance disorders, cognitive impairment, weakness, environmental hazards, confusion, visual impairment, and illnesses affecting the central nervous system and blood pressure. 2.a. Frail elderly individuals are often at greater risk for serious adverse consequences of falls. R1's diagnoses included: Major depressive disorder, diabetes mellitus, Alzheimer's disease atherosclerotic heart disease, pain in left hip, repeated falls, hypoglycemia, metabolic…

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, interview, and record review the facility failed to ensure room meal trays were delivered on time for 24 of 24 residents (R5, R8-R30) reviewed for timeliness of meals in a sample of 30. Findings include: A Daily Meal Time posting (undated) documents that the facility's breakfast is served at 7:30am, lunch at 12:00pm, and dinner at 5:30pm. On 8/8/23 V22 (R2's Family) stated when R2 was a resident at the facility, R2's room meal trays were not delivered in a timely manner. On 8/8/23 at 12:00p.m. residents were noted in the dining room being served lunch. At the same time, R5, R8-R30 remained in their rooms waiting for room trays to be delivered. At approximately 1:25pm. carts containing room trays were delivered to the resident halls for staff to deliver to residents' rooms. On 8/08/23 at 1:30 pm, V21 (Certified Nurse Aide/CNA) was serving room trays on the front right hallway before proceeding to finish passing room trays on the front left hallway. At 1:33 pm, V21 stated this was not the time that room trays are supposed to be passed to residents in their rooms.…

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, interview and record review the facility failed to ensure medications were not left at a resident's beside without determining the resident's ability to self-administer medications for one of one resident (R8) reviewed for self-administration of medications in a sample of 30. Findings include: A Self-Administration of Medications policy dated 11/3/14 states, For those residents who self-administer medications, the interdisciplinary team verifies the resident's ability to self-administer medications by means of a skill assessment conducted on a (quarterly) basis or when there is a significant change in condition. A Medication Administration Policy dated 2/2014 states, Residents will be positively identified prior to medication administration and shall not be left alone until the medication is consumed or refused. On 8/8/23 at 8:55a.m. V7 (Registered Nurse) was standing at a medication cart in the hallway. V7 stated that nurses are not supposed to leave medications at residents' bedside but, instead, must watch resident's take their medications before leaving the…

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, interview and record review the facility failed to prevent a greater than 5% medication error rate during the medication pass when there were two medication errors out of 25 opportunities which equals an 8% medication error rate affecting one of three residents (R8) reviewed for medication errors in a sample of 30. Findings include: A Medication Administration Policy dated 2/2014 states, Drugs will be administered in accordance with orders of licensed medical practitioners of the State in which the facility operates. In addition, this policy states, The medication administration record (MAR) will be verified against physician's orders. On 8/8/23 from 8:50am to 9:30a.m V7 (registered Nurse/RN) was administering residents' morning medications (Meds). V7 administered a total of 25 meds during that time. At 8:55am, while preparing to dispense and administer R8's morning meds, V7 scrolled to R8's MAR, which contains physician's orders for medications, to review the meds that were due for R8 at that time. V7 dispensed into a cup the correct dosages of R8's…

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.