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NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to ensure oxygen tubing was dated and regularly changed for 3 of 3 sampled residents (Residents 7, 112 and 87) when reviewed for respiratory care. This failure placed residents at risk for unmet care needs, medical complications, and a diminished quality of life. Findings included . Review of a facility's policy titled, Oxygen Therapy, dated 1/2020 showed oxygen tubing, cannula or mask, humidification was to be changed weekly by nursing staff. An additional policy titled, Small Volume Nebulizer (SVN, a device used to deliver medication in the form of a fine mist, or aerosol, to the lungs through inhalation) and a Metered-Dose Inhaler, (MDI, a device that delivers a specific amount of medication to the lungs in a form of a short burst of aerosol medication via inhalation), treatment, dated 11/2023 showed the facility's clinical team members were responsible in the delivery of the intermittent aerosol therapy by SVN. The equipment was to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide an opportunity for a resident to see the new location and meet new roommates for 1 of 1 Sample Resident (Resident 31) when reviewed for room changes. This failure placed residents at risk for psychosocial decline and diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 31 admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, prevents airflow to the lungs causing breathing issues), generalized muscle weakness and was able to make needs known. During an interview on 05/05/2025 at 2:26 PM, Resident 31 stated they had moved three times within the last few months. Resident 31 stated they were unhappy with the previous room move as they did not have a choice in the move and did not get to see the new room prior to moving. Review of the EHR showed Resident 31 had room moves on 02/18/2025, 02/27/2025 and 04/22/2025. Review of a progress…

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 obtain a court-appointed guardianshipyes (legal process where a court appoints someone to make decisions for a person who is unable to do so for themselves) and/or to obtain and periodically review a resident's advanced directive (AD, a legal document that establishes a medical decisionmaker if you are unable to make decisions for yourself) for 2 of 3 sampled residents (Residents 14 and 99) when reviewed for advanced directive. This failure placed residents at risk of not having an established decisionmaker, lack of ability to direct care, and a diminished quality of life. Findings included . Resident 14 Review of the electronic health record (EHR) showed Resident 14 initially admitted to the facility on [DATE] and was able to make needs known. The quarterly minimum data set (MDS, a required assessment tool), dated 03/21/2025, showed Resident 14 had diagnoses that included dementia (a group of thinking and social symptoms that interferes with daily…

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 prevent the use of chemical restraints for 1 of 5 sampled residents (Resident 83) reviewed for unnecessary medications. This failure placed residents at risk of side-effects from the medications, unnecessary chemical restraints, and a diminished quality of life. Findings included . Resident 83 admitted to the facility on [DATE] with diagnoses that included vascular dementia (a condition resulting in symptoms such as memory loss, confusion, and difficulty with reasoning and planning) and depression. The quarterly minimum data set (MDS), an assessment tool, dated 03/07/2025, showed Resident 83 was confused and dependent on staff for care. Review of the electronic heath record (EHR) showed Resident 83 was taking Seroquel (an antipsychotic medication), dated 03/31/2024, Depakote (an antiseizure medication used for mood stabilization), and Mirtazapine (an antidepressant medication). Review of provider orders showed Resident 83 started on…

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 identify and report an allegation of abuse for 1 of 1 sampled resident (Resident 31) when reviewed for abuse. This failure placed residents at risk for unidentified and repeated potential abuse, neglect and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 31 admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, prevents airflow to the lungs causing breathing issues), generalized muscle weakness, and was able to make needs known. Review of the facility's policy titled, Abuse, Neglect and Exploitation dated October 2022, showed, As part of the resident abuse prevention, the staff will . identify the different types of abuse to include certain resident to resident altercations .immediately investigate . report all alleged violations of abuse within specified timeframes. During an interview on 05/05/2025 at 2:29 PM, Resident 31 stated they…

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 provide and/or maintain documented care conferences in a timely manner for 2 of 3 sampled residents (Residents 72 and 77) when reviewed for care planning. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . Resident 72 Review of the electronic health record (EHR) showed Resident 72 admitted to the facility on [DATE] with diagnoses that included diabetes (too much sugar in the blood) and high blood pressure and was able to make needs known. During an interview on 05/05/2025 at 2:29 PM Resident 72 stated they had not gone to a care conference meeting. Review of Resident 72's EHR on 05/08/2025 showed no documentation that a care conference had occurred. Resident 77 Review of the EHR showed Resident 77 admitted to the facility on [DATE] with diagnoses that included heart failure, arthritis (swelling of the joints), and depression. Resident 77 was able to make needs known. During an interview on…

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 services provided met professional standards of practice by accurately documenting behavior monitoring for 1 of 3 residents (Resident 83) reviewed for dementia care. This failure placed residents/staff at risk of unmet care needs, unnecessary medications, and a diminished quality of life. Findings included . Resident 83 admitted to the facility on [DATE] with diagnoses that included vascular dementia (a condition resulting in symptoms such as memory loss, confusion, and difficulty with reasoning and planning) and depression. The quarterly minimum data set (MDS), an assessment tool, dated 03/07/2025, showed Resident 83 was confused and dependent on staff for care. Observation on 05/06/2025 at 1:05 PM showed Resident 83 was awake, alert, and pleasantly confused. Observation on 05/07/2025 at 1:36 PM showed Resident 83 was with eyes closed in their wheelchair. Observation on 05/07/2025 at 2:54 PM showed Resident 83 was in bed with…

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 provide prompt services to maintain vision for 1 of 3 sampled residents (Resident 23) when reviewed for communication/sensory. This failure placed the resident at risk of unmet vision needs, inability to perform activities of daily living, inability to participate in leisure activities and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 23 readmitted to the facility on [DATE] with diagnoses that included diabetes (too much sugar in the blood) and depression. The quarterly minimum data set (MDS, a required assessment tool) dated 02/27/2025, showed Resident 23 had adequate vision with corrective lenses. During an interview on 05/05/2025 at 12:56 PM Resident 23 stated that they had gone to the eye doctor sometime in February of this year (2025) and received a prescription for new glasses; however, they had not received them, and staff were aware. Review of Resident 23's neuro-ophthalmology…

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 residents with limited range of motion received the necessary services to maintain their level of functioning and/or prevent decline for 1 of 3 sampled residents (Resident 31) when reviewed positioning/mobility. This failure placed the residents at risk for decreased range of motion (ROM), increased pain, and diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 31 admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, prevents airflow to the lungs causing breathing issues), generalized muscle weakness and was able to make needs known. Review of the care plan, revised on 02/11/2025, showed Resident 31 had an activities of daily living (ADL) self-care performance deficit related to impaired balance. Review of the admission minimum data set (MDS, an assessment tool), dated 02/17/2025, showed Resident 31 had impairment 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 observation, interview, and record review the facility failed to accurately assess and monitor pain for 2 of 4 residents (Residents 20 and 89) when reviewed for pain management. This failure placed the residents at risk for unidentified and unmanaged pain and a decreased quality of life. Findings included . Resident 20 Review of the electronic health record (EHR) showed Resident 20 was re-admitted to the facility on [DATE] with a diagnosis of chronic kidney disease with heart failure and was admitted to hospice (end of life care) services 01/16/2025. The resident was able to make needs known. During an interview and observation on 05/07/2025 at 9:23 AM, Resident 20 stated My chest and my kidneys hurt every day. It's getting worse. My belly hurts and my legs hurt all the time. I don't request pain medication unless I can't bear the pain because they are too busy. Review of the monthly pain management review dated 4/30/2025 showed a total of six as-needed (PRN) narcotic pain medications administered in…

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 residents who experienced dementia-related behaviors received care and services to attain the highest practicable physical, mental, and psychosocial well-being when it did not identify and implement person-centered, individualized interventions for 1 of 3 sampled residents (Resident 83) when reviewed for dementia care. This failure placed residents at risk of unmet care needs, unnecessary medications, and a diminished quality of life. Findings included . Resident 83 admitted to the facility on [DATE] with diagnoses that included vascular dementia (a condition resulting in symptoms such as memory loss, confusion, and difficulty with reasoning and planning) and depression. The quarterly minimum data set (MDS), an assessment tool, dated 03/07/2025, showed Resident 83 was confused and dependent on staff for care. Review of the EHR showed Resident 83 was taking Seroquel (an antipsychotic medication) for a diagnosis of dementia with…

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 promptly resolve grievances for 1 of 5 sample residents (Resident 1) reviewed for grievances and missing property. The failure to thoroughly investigate a grievance and either resolve the resident grievance timely or provide an explanation if the grievance could not be resolved placed residents at risk for frustration and a diminished quality of life. Findings included . Review of the facility Resident and Family Grievances policy and procedure, dated 01/2024, showed Staff E, Social Services Director was the designated Grievance Official. Grievances may be in the form of verbal complaint, or written complaint, to a staff member, Grievance Official, to an outside party, or during resident or family council meetings. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form, or assist the resident or family member to complete the form. The Grievance Official will take steps to resolve…

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 ensure 1 of 3 sample residents (Resident 1) reviewed for Pressure Ulcers (PU - injury to the skin and underlying tissue due to prolonged pressure) received the necessary care and services, consistent with professional standards of practice, to prevent new ulcers from developing, identify and treat PUs. Failure to implement wound prevention, interventions, and to report on worsening conditions, placed residents at risk for deteriorating PU, increased discomfort, and a diminished quality of life. Findings included . Review of the 11/27/2024 admission Minimum Data Set (MDS - an assessment tool) showed Resident 1 was alert, oriented and was assessed to require substantial/maximal assistance with bed mobility, and had diagnoses including Peripheral vascular disease, and Diabetes Mellitus. Resident 1 was assessed at risk of developing pressure ulcers, and had no pressure ulcers, no venous ulcers, no arterial ulcers, no diabetic foot ulcers and no open…

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, interviews and record review, the facility failed to protect a resident's right to be free from mental and verbal abuse for 1 of 3 sample residents (Resident 2) reviewed for resident to resident altercation. This failure placed residents at risk of verbal and mental abuse, psychosocial harm, and diminished quality of life. Findings included . Review of the facility policy titled, Abuse, Neglect and Exploitation, dated 10/22, showed the facility would implement policies and procedures to prevent and prohibit all types of abuse, that achieved the identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict. The policy further showed the facility would make efforts to ensure all residents were protected from physical and psychosocial harm during and after the investigation. Examples included room changes, if necessary, to protect the resident from the alleged perpetrator. Review of Resident…

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 proper labeling of insulins in 1 of 4 medication carts (700-hall Medication Cart) reviewed for medication storage. This failure placed residents at risk for receiving expired medications, ineffective medications, and a diminished quality of life. Findings included . Observation on 06/05/2024 at 9:22 AM showed two multi-dose insulin pens with no open date or expiration date in the 700-hall medication cart. During an interview on 06/05/2024 at 9:35 AM, Staff N, Licensed Practical Nurse, stated insulin pens should be dated when opened and there were two undated pens in the 700-hall medication cart. During an interview on 06/05/2024 at 11:10 AM, Staff B, Director of Nursing Services, stated the expectation was to date open insulins with the open date and expiration date. Reference WAC 388-97-1300(2) .

Based on observation and interview, the facility failed to ensure foods were sanitarily stored in the kitchen and 3 of 4 resident refrigerators (Ocean, Mountain, and Narrows Dining) when reviewed for kitchen. These failures placed residents at risk of consuming contaminated foods, avoidable foodborne illness, and a diminished quality of life. Findings included . Observation on 06/02/2024 at 9:38 AM showed the facility walk-in refrigerator had four bags of raw chicken sitting in approximately one inch of bloodied water, one container of minced garlic without date label, a container of pudding with no date, a package of bacon with a use by date of 05/30, a salad uncovered, undated, and severely dried, four trays of raw fish on a rack uncovered and undated, and a container of sliced tomato without date label. The walk-in freezer showed a rack with several types of raw meat left exposed to the air and severely dried. During an interview on 06/02/2024 at 9:47 AM, Staff Q, Dietary Aid, stated the container of garlic, pudding, and bacon needed to be thrown out. Staff Q stated the rack 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 have psychotropic (medications that affect a person's mental state) medication consents signed and in place prior to resident receiving medications for 3 of 5 sampled residents (Residents 40, 78 & 119) reviewed for psychotropic medication use. This failure placed the residents at risk for adverse side effects and diminished quality of life. Findings included . Review of the facility's document titled, The Process of Informed Consent, dated December 1998, showed to be fully informed, a nursing facility resident must receive appropriate and meaningful information relative to their health care decision-making. The procedure included language that residents could reasonably be expected to understand; Current medical condition or prognosis, Expected medical condition or prognosis, Suggested treatment or services, Anticipated results of proposed treatment, Recognized serious possible risks, complications and anticipated benefits involved in treatment and in…

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 that residents received treatment and care in accordance with professional standards of practice for 5 of 25 sampled residents (Residents 107, 30, 42, 78, and 2) reviewed for quality of care. Failure to consistently monitor and document edema (swelling caused by too much fluid trapped in the body's tissues) for Resident 107 and 30, provide management of a surgical wound for Resident 42, ensure adequate positioning was provided for Resident 78, and notify the provider of an acute change in respiratory status for Resident 2 placed the residents at risk for worsening conditions, discomfort, and a decreased quality of life. Findings included . Resident 42 Resident 42 admitted to the facility on [DATE] with a diagnosis of fracture of left femur with subsequent placement of an intramedullary rod (a medal rod used to stabilize long bone fractures within the cavity of the bone). During an interview on 06/03/2024 at 10:08 AM, Resident 42'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 environments were free from accident hazards for 3 of 6 sampled residents (Residents 121, 68, and 4) when reviewed for accident hazards. The facility failure to secured medications (Resident 121), investigate falls and implement fall precautions (Resident 68), and ensure bedrails were firmly installed (Resident 4) placed residents at risk of avoidable injury, hospitalization, and a diminished quality of life. Findings included . <Unsecured Mediations> Observation on 06/02/2024 at 10:07 AM showed a refrigerator in the Narrows dining room with a lunch bag. Observation showed that the lunch bag contained a lidocaine patch (a topical medication to reduce pain). During an interview on 06/02/2024 at 10:42 AM, Staff A, Administrator, stated all medications should be locked in a medication cart or medication room and should not be accessible to residents. Staff A stated the lidocaine patch should not be left in the resident…

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 offer, educate, and obtain consent for influenza and/or pneumococcal vaccines for 5 of 5 residents (Residents 74, 90, 102, 108, and 120) when reviewed for influenza and pneumococcal immunizations. These failures denied residents the opportunity to make an informed decision regarding receiving immunizations and/or placed the residents at risk for communicable diseases, complications of other medical conditions, hospitalization, and death. Findings included . Review of the facility policy titled Vaccination for Residents dated 01/28/2022 showed that all residents would be offered vaccines that aided in preventing infectious diseases. Prior to receiving a vaccination, the resident or their representative would be provided information and education on the benefit and potential side effects of the vaccination and documented in the resident's medical record. Review of Resident 74's electronic health record (EHR) showed the resident admitted to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to offer, educate, and obtain consent for Covid-19 vaccinations for 5 of 5 residents (Residents 74, 90, 102, 108, and 120) when reviewed for immunizations. This failure denied residents the opportunity to make an informed decision regarding receiving Covid-19 vaccines and/or placed the residents at risk for complications, hospitalization, and a decreased quality of life. Findings included . Review of the facility policy titled Vaccination for Residents dated 01/28/2022 showed that all residents would be offered vaccines that aided in preventing infectious diseases. Prior to receiving a vaccination, the resident or their representative would be provided information and education on the benefit and potential side effects of the vaccination and this would be documented in the resident's medical record. Review of Resident 74's electronic health record (EHR) showed the resident admitted to the facility on [DATE]. No documentation was in the EHR that staff…

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

Based on observation and interview, the facility failed to maintain kitchen equipment in safe working order for a griddle/oven combo unit and 1 of 4 freestanding refrigerators when reviewed for kitchen. These failures places residents at risk of eating contaminated food, avoidable foodborne illness, fire injury, smoke inhalation, and a diminished quality of life. Findings included . Observation on 06/02/2024 at 9:35 AM showed a freestanding refrigerator with a tray of sandwiches inside. Observation showed standing water on the bottom of the refrigerator and droplets of condensation gathered on the ceiling. A metal container was on a crossbar inside the refrigerator and had approximately two inches of water and a small screwdriver and screws inside. Observation on 06/02/2024 at 9:48 AM showed a griddle/oven combo unit with a grease trap which stuck out approximately one and a half inches. Below the grease trap there was dried grease on the side of the unit and on the ground underneath. Observation on 06/04/2024 at 11:21 AM showed the freestanding refrigerator continued with water on…

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

Based on observation and interview, the facility failed to inspect bedrails as part of a regular maintenance program. This failure placed residents at risk of falling, entrapment, avoidable injury, and a diminished quality of life. Findings included . During an interview on 06/05/2024 at 11:33 AM, Staff C, Registered Nurse/Unit Manager, stated there was no regular system for inspecting bedrails and staff were expected to notice loose bedrails and notify maintenance. During an interview on 06/05/2024 at 1:37 PM, Staff B, Director of Nursing Services, stated staff were to notice loose bedrails and notify maintenance. During an interview on 06/05/2024 at 2:40 PM, Staff M, Maintenance Director, stated there was no system for regular inspection of bedrails. Staff M stated staff would inform maintenance that bedrails needed tightening as they were discovered. During an interview on 06/05/2024 at 3:05 PM, Staff A, Administrator, stated that inspection of bedrails should be part of a regular preventative maintenance schedule. SEE F689 Reference WAC 388-97-2100 .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to ensure residents were free from physical restraints with the use of a mobility device for 1 of 3 sampled residents (Resident 78) when reviewed for physical restraints. This failure placed residents at risk for avoidable injury, psychological harm, and decreased quality of life. Findings included . Resident 78 was admitted to the facility on [DATE] with multiple diagnoses to include Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements and difficulty with coordination), asthma, and depression. Resident 78 was able to make needs known. Observation on 06/02/2024 at 11:15 AM showed Resident 78 using a tilt in space wheelchair (w/c) with a pressure alarm attached to it. Resident 78 was leaning to the front right. A staff member repositioned the resident and tilted the w/c back. Review of Resident 78's electronic health record showed no documentation of a restraint assessment or provider order for 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to accurately assess a pressure ulcer/skin condition for 1 of 3 sampled residents (Resident 7) reviewed for pressure injury. This failure placed the resident at risk for health complications and diminished quality of life. Findings included . Resident 7 was admitted to the facility on [DATE] with multiple diagnoses to include Alzheimer's disease (a brain disorder that destroys memory and thinking skills), adult failure to thrive, and abnormal weight loss. Resident 7 was not able to make needs known. Review of a quarterly Minimum Data Set (MDS), an assessment tool, dated 05/20/2024, showed Resident 7 had two unstageable pressure ulcers (injury to skin due to pressure) which were present on admission. During an interview on 06/05/2024 at 10:06 AM, Staff K, MDS Nurse, stated it was coded inaccurately as Resident 7's pressure ulcers developed after admission into the facility. During an interview on 06/05/2024 at 11:22 AM, Staff B, Director of Nursing…

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 services provided met professional standards of practice for 3 of 4 sampled residents (Residents 2, 88 & 28) reviewed for anticoagulant (blood thinner medication) use and/or indwelling urinary catheter (IUC, a tube inserted in the body to empty the bladder of urine) care. The facility failed to ensure Resident 28 and 88's provider's orders for IUC were in place and/or accurate, and Resident 2's anticoagulant monitoring for side effects were documented. These failures placed residents at risk of medical complications, unmet needs, and a poor quality of life. Findings included . Review of Lippincott's Manual of Nursing Practice, dated 2024, showed that for patients receiving anticoagulation therapy observe carefully for any possible signs of bleeding and report immediately so that anticoagulant dosage may be reviewed and altered, if necessary. Resident 2 Resident 2 admitted to the facility on [DATE] with a diagnosis of atrial…

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 provide necessary treatment to heal pressure injuries for 1 of 3 sampled residents (Resident 7) reviewed for pressure injuries. This failure placed the resident at risk for worsening pressure injury, infection, and diminished quality of life. Findings included . Resident 7 admitted to the facility on [DATE] with multiple diagnoses to include Alzheimer's disease (brain disorder that destroys memory and thinking skills), adult failure to thrive, and abnormal weight loss. Resident 7 was unable to make needs known. Observation and interview on 06/05/2024 at 1:24 PM, during a dressing change, showed Resident 7 had a dressing on the right outer ankle area that was dated 05/31/2024. Staff L, Licensed Practical Nurse, stated the dressing was not changed on 06/03/2024 as ordered. Review of Resident 7's treatment administration record for June 2024 showed missing documentation for multiple orders on 06/03/2024 during day shift. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure a fluid restriction for provided and monitored for 1 of 3 sampled residents (Resident 54) reviewed for nutrition. This failure placed the resident at risk of fluid overload, avoidable swelling, and a diminished quality of life. Findings included . Resident 54 admitted to the facility on [DATE] with diagnoses of pulmonary edema (water in the lungs) and kidney failure. Review of Resident 54's provider's orders showed a fluid restriction of 1500 milliliter (ml) with nursing to provide 600 ml and dietary 900 ml. Review of Resident 54's medication administration record (MAR) showed two sections to document the amount of fluid consumed. The first section showed for nursing and dietary to document the amount consumed from 6:00 AM with no end time. The second section showed for nursing and dietary to document the amount consumed from 6:00 PM to 6:00 AM. There was no location to total the daily amount consumed and no instructions on how much liquid 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure as needed (PRN) psychotropic medications (affecting the mind) were limited to 14 days for 1 of 5 sampled residents (Resident 6) when reviewed for unnecessary medications. This failure placed the residents at risk for receiving unnecessary psychotropic medication, avoidable medication side effects, and a diminished quality of life. Findings included . Resident 6 admitted to the facility on [DATE] with multiple diagnoses to include dementia (brain disorder that impairs memory and thinking skills), anxiety, and congestive heart failure. Resident 6 was unable to make needs known. Review of Resident 6's provider's orders showed an order for lorazepam (an antianxiety medication) every 2 hours PRN started on 05/04/2024 and without a stop date. Review of Resident 6's pharmacy recommendations dated 05/14/2024 showed a recommendation to stop lorazepam PRN after 14 days. Review of Resident 6's medication administration record showed that Resident 6 was…

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

Based on observation and interview, the facility failed to maintain the alarm function of two of three emergency exits, open to the outside and leading off the facility property, (600 hall and 700 hall) reviewed for safety/accident prevention. This failure placed cognitively impaired residents, residents who wander and have exit-seeking behaviors, at risk for being able to leave the facility unnoticed by staff, placing their safety at risk. Findings included . In observation on 03/12/2024 at 3:46 PM, at the end of the 700 hall, there was a double door exiting to an open unsecured side of the facility property, with the sidewalk and street beyond. Signs on the door read, Emergency exit only. Alarm will sound. When the door was opened by Staff E, Maintenance Staff, the alarm did not sound. In observation on 03/12/2024 at 3:51 PM, at the end of the 600 hall, there was a double door, leading to a small fenced area, with a gate exiting to the main parking lot in the front of the facility, which was open to the sidewalk and street beyond. Signs on the door read, Emergency exit only. Alarm…

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 implement an infection control and prevention program that ensured that staff were fit tested (a process for determining whether a respirator properly fits the face of the person who wears it) for N-95 respirators (a type of disposable face mask that forms a tight seal to the face and is able to filter out airborn particles and pathogens [bacteria, virus, or other microorganism that can cause disease]) upon hire, and annually thereafter, for six of six staff (Staff D, G, H, I, J, and K) reviewed for N-95 respirator fit testing. In addition, these staff were working with residents during a COVID-19 (contagious respiratory disease caused by the SARS-CoV-2 virus) outbreak in the facility. This failure placed residents and staff at risk for exposure to, and spread of, communicable diseases such as COVID-19. Findings included . Review of the facility COVID-19 outbreak line list (a table that contains information about each case in an outbreak), on 03/06/2024, showed that the facility was currently experiencing a COVID-19…

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 interviews and record reviews, facility failed to ensure a resident-to-resident altercation was identified and investigated for 1 of 4 residents (Resident 1) reviewed for abuse allegations. Failure to identify and thoroughly investigate an abuse allegation placed residents at risk for recurrence of alleged abuse and a diminished quality of life. Findings included . Review of the facility policy, Abuse, Neglect and Exploitation, dated October 2022, showed that when suspicion or reports of abuse, neglect or exploitation occur, an immediate investigation was warranted. According to the policy, the facility would, during and after investigation: • Respond immediately to protect the alleged victim. • Examine the alleged victim for sign of injury. • Increase supervision of alleged victim and residents. • Make room or staffing changes if needed to protect the resident. • Provide emotional support. • Revise care plan if resident's medical, nursing, physical, mental or psychosocial needs or preferences changed…

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 observations, interviews, record review, and policy review, the facility failed to ensure the kitchen was maintained and operated in a sanitary manner to prevent the potential spread of foodborne illness to all 130 residents. Specifically, the facility failed to ensure sanitizer solutions were at the proper concentration, tray line temperatures were within safe ranges, dishes were clean, hair coverings were worn, foods were labeled, and environmental surfaces were free of excessive grime, crumbs, and black substance. Findings include: Review of the Food Temperatures policy dated 01/02/23 and provided by the facility revealed, Food will be served at proper temperature to ensure food safety .Record reading on Food Temperature Log form at beginning of tray line. If temperatures do not meet acceptable serving temperatures, reheat the product or chill the product to the proper temperature. Take the temperature of each pan of product before serving. Acceptable serving temperatures are . hazardous salads and desserts <41 degrees (Fahrenheit) . Review of the Sanitation of Equipment…

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, document review, interview and facility policy review, the facility failed to ensure proper infection control in the following areas: proper infection control practices with residents on transmission-based precautions (TBP) for COVID and the timely notification of the health department of the COVID outbreak; providing diagrams for the water flow in the facility and testing waterborne pathogens; transporting uncovered clean clothing throughout the facility. These deficient practices had the potential to affect all 130 residents and to allow exposure to non-COVID residents to COVID, waterborne pathogens and their clothing to dust and germs. Findings include: 1. Review of the facility policy titled, Infection Prevention and Control dated 01/28/22 revealed, Policy: This facility will facilitate the safe care of all resident and staff with known or suspected communicable disease by establishing and maintaining an infection prevention and control program designed to provide a safe sanitary, and…

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 ensure that an establish advanced directive (AD) was enacted as directed for 1 of 5 residents (Resident 19) reviewed for AD. This failure denied the resident the opportunity to direct their healthcare during an event when they were unable to make decisions or communicate their healthcare preferences. Findings included . ADVANCE DIRECTIVES (AD) An AD is a written instruction, such as a living will or durable power of attorney [DPOA] for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. PHYSICIAN ORDERS FOR LIFE-SUSTAINING TREATMENT (POLST) Federal regulation defined a POLST as .a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient'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, record review, and policy review, the facility failed to notify one of 31 sampled residents (Resident (R)109) physician and family member of an injury sustained to R109's toe first discovered on 06/20/23. This resulted in a delay for a referral to the podiatrist. Findings include: Review of the facility's policy titled, Skin Care Protocol & Monitoring dated 08/2019 and provided by the facility revealed, Complete resident incident report. Incident Report must include the following: vi. Notification of MD [medical doctor] and family. Review of the facility policy titled, Notification of Resident Change of Condition dated 02/2012 and provided by the facility revealed, Unit Coordinators are responsible to ensure that residents' physician and responsible party are notified whenever there is a significant change of condition in a resident's physical, mental or psychological status including accidents . Review of the undated admission Record in the electronic medical record (EMR) under…

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

Based on observation, record review, interview and facility policy review, the facility failed to ensure resident equipment was maintained and in good repair for four (Resident (R)11, R51, R69, and R100) of 31 sampled residents. The resident's wheelchair arms had cracked or missing protective material exposing the cloth like material. This deficient practice had the potential to allow residents with frail skin to receive soars or prevent the wheelchairs from being thoroughly clean, increasing risk of infection. Finding include: Review of the facility policy titled, Resident Transport Wheelchair Cleaning dated 01/28/22 revealed, Policy: The intent of this policy is to establish a procedure for the proper and safe technique to be used for cleaning manually operated transport wheelchairs. Review of R11's undated admission Record under the Profile tab in the electronic medical record (EMR) revealed and admission date of 09/13/12 with diagnoses of Alzheimer's disease and dementia. During observations on 08/14/23 at 11:33 AM, 08/15/23 at 12:45 PM, 08/16/23 at 11:14 AM, and 08/17/23 at…

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 refer one (Resident (R) 70) of one resident reviewed for Preadmission Screening and Resident Review (PASRR) residents for a Level II, with a qualifying diagnosis of mental illness in the sample of 31. This had the potential to cause R70 to not receive necessary mental health services. Findings include: Review of R70's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed R70 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, anxiety disorder unspecified and post-traumatic stress disorder (PTSD), unspecified. Review of R70's Preadmission Screening and Resident Review (PASRR) Level I Screening Tool, dated 07/24/23 and located under the Misc (Miscellaneous) tab of the EMR, revealed R70 did not have a diagnosis or evidence of a major mental illness and had no significant impairment in functioning related to a suspected or known diagnosis of mental illness. Review of R70'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, record review and policy review, the facility failed to ensure one out of one resident reviewed for non-pressure skin conditions (Resident (R)109) received adequate nursing care and services to address an injury to her toe. Specifically, the facility failed to complete an initial investigation in accordance with facility policy (Incident Report), initiate subsequent monitoring and documentation (alert charting), and determine if interventions were needed to protect the injured area and to prevent re-injury. Findings include . Review of the facility's policy titled, Skin Care Protocol & Monitoring dated 08/2019 and provided by the facility revealed, Purpose - To provide the Nursing staff with a planned, organized systematic approach to the identification, assessment, and treatment of residents at risk for or having impaired skin integrity .Procedure - Assess the skin integrity of every resident upon admission and weekly thereafter . The assessment must include the entire body…

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 the use of an indwelling urinary catheter (a tube which drains urine from the bladder into a collection bag) had the catheter bag attached as ordered by the provider and a privacy bag for 1 of 1 resident (Resident 173) reviewed for urinary catheters. This failure placed the residents at risk for further complications, prolonged therapy, and unmet care needs. Findings included . Review of a facility's policy titled, Insertion, Removal and Maintenance of an Indwelling Urinary Catheter dated 10/2019, showed that policy and procedure for routine drainage bag care included staff to use either a drain or leg bag as ordered and provide privacy. Review of the admission Minimum Data Set (MDS, an assessment tool) dated 07/12/2023 showed that Resident 173 was admitted to the facility on [DATE] with multiple diagnoses to include heart, lung, and kidney disease. The resident's electronic health record (EHR) showed that the resident had an…

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

Based on observation, interview, and record review, the facility failed to ensure that narcotics storage refrigerators were secured for 1 of 3 medication storage rooms (Ocean) and medication storage rooms were secured for 1 of 3 medication rooms (Alpine) when reviewed for medication storage. In addition, the facility failed to ensure a bottle of Virex (a germicidal / disinfectant cleaning material) was separately stored for 1 of 3 medication storage rooms (Mountain) and that personal staff hydration was not stored within a facility's medication cart (700 Hall). These failures placed residents at risk to have unintended access to drugs and biologicals that should have been locked, an increased risk of drug diversion, and potential drug misuse. Findings included . A document titled, Controlled Substance Administration and Accountability, dated 05/20/2023 showed that it was the facility's policy to ensure all medications housed on the premises will be stored in the pharmacy and/or medication rooms according to the manufacture's recommendations and sufficient to ensure proper…

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.