Every finding on record at Pruitthealth - Washington

Based on observations, staff interviews, and review of the facility's policy titled, Labeling, Dating, and Storage, the facility failed to ensure opened food items in the walk-in refrigerator, stand-alone freezer, and dry storage area were labeled, dated, and discarded by expiration date. In addition, the facility failed to ensure sanitary condition in the kitchen. The deficient practices had the potential to affect 44 out of the 45 residents who were on an oral diet.Findings Include:Review of facility's policy titled Labeling, Dating, and Storage revised date 11/11/2022 revealed in Procedures section, 1. Food and beverage items will have an identifying label as well as received date and opened date, as applicable; for items prepared onsite, a use by date will also be indicated.During the initial tour on 02/27/2025 at 06:35 AM with [NAME] DD, the inspection of food in the dry storage area revealed multiple opened and unlabeled packages: one 10-lb (pound) enriched macaroni product, one 10-lb plain breadcrumbs, one 5-lb white cake mix, one 5-lb brownie mix, one 11.3-ounce turkey gravy mix, one 11.3-ounce chicken gravy mix, one 13.29-ounce brown gravy, and one 16-ounce baking soda. The walk-in cooler/refrigerator was inspected and revealed 17- 8 fluid oz (ounce) cartons of chocolate milk, which had an expiration date of 02/25/2026. [NAME] DD verified the count and expiration date. The stand-alone freezer was inspected and revealed two packs of 12 sausages, each containing 40 oz sausages, with an expiration date of 12/05/2025. Furthermore, one clear trash like bag, containing 50 garlic sticks, along with a one-gallon bag marked as chicken, were observed to lack the necessary labeling or dating.Observation on 02/28/2026 at 10:17 AM with the Dietary Manager (DM) during the follow-up tour revealed four air vents located next to the drying area for clean dishes and the food preparation station that contained a black-like substance, rust accumulation, and dust. Additionally, black-like debris was found beneath the dishwasher. Observations made beside the steamtable during serving showed one vent and ceiling with black-like dust. This was confirmed with the DM and Maintenance Director.An interview on 02/28/2026 at 10:26 AM with the Maintenance Director confirmed that the kitchen had not been cleaned this month, which was typically done at the start of each month. The Maintenance Director explained that the vents in the kitchen, particularly those near the cooking and cleaning areas, showed signs of grease accumulation and dust on top. The Maintenance Director shared that he did not maintain a log or have a fixed schedule for cleaning the vents and confirmed that it had been over a year since they were last cleaned. The Maintenance Director also indicated that this situation posed a risk of food contamination.An interview conducted on 02/28/2026 at 10:31 AM with the DM disclosed that she was made aware of all unlabeled and undated items observed with [NAME] DD. She indicated that she would begin searching inside open boxes for used items placed by the staff and would carry out any in-service training. DM affirmed that it was everyone's responsibility to check, particularly if they handled or opened the item. The DM also mentioned that she had not previously noticed the condition of the vents as she did not typically look upwards, but she woukld make an effort to do so more frequently. The DM confirmed the vents looked rusted and black.

Based on observation, staff interview, record review, and review of the facility's policy titled Cleaning Schedule Policy, the facility failed to maintain the ice machine in a clean, sanitary manner. The deficient practice had the potential to cause illness to 43 out of 45 residents who consumed an oral diet. Findings include: Review of the facility's policy titled Cleaning Schedule Policy dated 9/29/2022 under the Policy Statement revealed, It is the policy of [Name] that the Dietary Manager prepares a list of all cleaning tasks and posts them in the Dietary Department. It is the Dietary Manager's responsibility to develop and enforce the cleaning schedules and to monitor the completion of assigned cleaning tasks to promote a sanitary environment. Review of the facility's Ice Machine Cleaning Schedule Form revealed the unit should be cleaned monthly and indicated that it had been cleaned on 10/4/2024. Review of the facility's Direct Supply TELS (a web-based platform/service records) Work History Report indicated the ice machine was cleaned on 10/4/2024. During an observation on 11/17/2024 at 1:16 pm of the kitchen with the Dietary Manager (DM) revealed, the ice machine in the dining room next to the kitchen. Observation of the interior side of the ice machine revealed a black substance at both hinges of the lid. Interview with the DM stated the Maintenance Director (MD) was responsible for cleaning the ice machine, but she was not sure how often the unit should be cleaned or the last time it was cleaned. Observation and interview on 11/17/2024 at 1:45 pm with the MD, confirmed the black film on the interior side of the ice machine. He stated he cleaned the unit monthly and as needed and that he last cleaned it a couple of weeks ago. The MD revealed he should look inside the unit more frequently to make sure it remained free of the filmy substance. Observation and interview on 11/17/2024 at 3:30 pm with the DM revealed, the unit was cleaned and that she would help monitor the unit more frequently for cleanliness.

Based on observations and staff interview, the facility failed to ensure the Packaged Terminal Air Conditioners (PTAC) were maintained to provide a clean and comfortable environment for 11 of 31 resident rooms (Rooms 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 21). Findings include: Observation of the filtration system in the PTAC on 11/17/2024 at 2:27 pm in room [ROOM NUMBER] revealed a fuzzy, grayish brown substance in and on the filter surface. Upon pulling out the filter, debris was also noted down inside the PTAC unit where the filter was housed. Observation of the filtration system in the PTAC on 11/17/2024 at 2:36 pm in room [ROOM NUMBER] revealed a fuzzy, grayish brown substance in and on the filter surface. Upon pulling out the filter, debris was also noted down inside the PTAC unit where the filter was housed. Observation of the filtration system in the PTAC on 11/17/2024 at 2:55 pm in room [ROOM NUMBER] revealed a fuzzy, grayish brown substance in and on the filter surface. Upon pulling out the filter, debris was also noted down inside the PTAC unit where the filter was housed. Observation of the filtration system in the PTAC on 11/17/2024 at 3:12 pm in room [ROOM NUMBER] revealed a fuzzy, grayish brown substance in and on the filter surface. Observation of the filtration system in the PTAC on 11/17/2024 at 3:22 pm in room [ROOM NUMBER] revealed a fuzzy, grayish brown substance in and on the filter surface. Upon pulling out the filter, debris was also noted down inside the PTAC unit where the filter was housed. Observation of the filtration system in the PTAC on 11/17/2024 at 3:43 pm in room [ROOM NUMBER] revealed a fuzzy, grayish brown substance in and on the filter surface. Upon pulling out the filter, debris was also noted down inside the PTAC unit where the filter was housed. Observation of the filtration system in the PTAC on 11/17/2024 at 3:55 pm in room [ROOM NUMBER] revealed a fuzzy, grayish brown substance in and on the filter surface. Upon pulling out the filter, debris was also noted down inside the PTAC unit where the filter was housed. Observation of the filtration system in the PTAC on 11/17/2024 at 4:14 pm in room [ROOM NUMBER] revealed a fuzzy, grayish brown substance in and on the filter surface. Upon pulling out the filter, debris was also noted down inside the PTAC unit where the filter was housed. Observation of the filtration system in the PTAC on 11/17/2024 at 4:30 pm in room [ROOM NUMBER] revealed a fuzzy, grayish brown substance in and on the filter surface. Upon pulling out the filter, debris was also noted down inside the PTAC unit where the filter was housed. Observation of the filtration system in the PTAC on 11/17/2024 at 2:27 pm in room [ROOM NUMBER] revealed a fuzzy, grayish brown substance in and on the filter surface. Upon pulling out the filter, debris was also noted down inside the PTAC unit where the filter was housed. Interview on 11/20/2024 at 11:05 am with the Maintenance Manager revealed, that the TELS (a web-based platform/service records) Building Management System has a reminder and check off for these to be done quarterly. He stated that he has told management that he feels cleaning should be done more often especially with the construction and painting currently taking place in the facility. The Maintenance Manager stated that all filters were cleaned this week after concerns were identified by surveyors.

Based on observations, staff interviews, record review, and review of the facility's policy titled Oxygen Administration, the facility failed to ensure oxygen was administered, provide documentation of monitoring for respiratory status, and to record oxygen saturation and nebulization treatments as ordered for one of two residents (R) R42 reviewed for oxygen. The deficient practice had the potential to affect R42's quality of life. Findings include: Review of the facility's policy titled Oxygen Administration dated 8/2/2023 Policy Statement revealed, It is the policy of [Name] to provide oxygen safely and accurately to appropriate patients/residents. Under the section titled Procedure revealed, number four Regulate liter flow to ordered/desired flow rate; number six, Monitor patient/resident's vital signs as warranted by patient/resident's condition and physician's orders. Review of the Electronic Medical Record (EMR) for R42 revealed, she admitted with diagnoses that included but were not limited to Chronic Obstructive Pulmonary Disease (COPD), acute respiratory failure, and chronic pulmonary embolism. Review of the Medication Administration Record (MAR) for R42's dated 11/1/2024 through 11/20/2024 revealed, orders to monitor vital signs weekly on Wednesdays (3-11pm) once a day on Wednesday to administer oxygen at 2 LPM (liters per minute) via nasal cannula as needed for shortness' of breath r/t (related to) COPD, check pulse ox check PRN (as needed), and administer ipratropium-albuterol solution for nebulization; 0.5 mg (milligram)-3 mg (2.5 mg base)/3 mL (milliliter) three times a day however there was no documentation on the MAR for monitoring respiratory status every shift, monitoring oxygen saturation or documentation of response and length of time for treatments. Observation on 11/17/2024 at 3:17 pm revealed, R42 oxygen flow rate at 5 LPM via nasal cannula. Observation on 11/17/2024 at 5:04 pm revealed, R42 oxygen flow rate at 5 LPM via nasal cannula. Observation on 11/17/2024 at 5:10 pm with Licensed Practical Nurse (LPN) DD, who was asked to R42's room confirmed the oxygen flow rate was at 5 LPM. Interview on 11/20/2024 at 1:50 pm with Registered Nurse (RN) EE revealed that he knew when R42 needed oxygen by checking her pulse oximetry and from signs and symptoms. He revealed that R42 did not have history of adjusting the flow rate. He revealed that he should be checking the flow rate to verify that it was correct every shift. He then stated that if a resident that receives a breathing treatment, they were supposed to be checking the vital signs before treatment and after treatment. He stated that it should be documented on the medication administration record (MAR) and/ or under the vital signs tab. He confirmed that they had not been documenting. Interview on 11/20/2024 at 1:59 pm with the Director of Health Services (DHS) revealed, breathing treatments documentation should include vital signs 15 minutes before treatment, 15 minutes post treatment and the duration of the treatment. She stated that the oxygen flow rate should be checked frequently at a regular basis, because she really does need her oxygen. Cross Reference F656

Based on observations, staff interviews, record review, and review of facility's policy titled Care Plans, the facility failed to follow a care plan for one of two residents (R) R42 reviewed for oxygen. Findings include: Review of the facility's policy titled Care Plans with dated 7/27/2023 under the section titled Definitions revealed, Person-Centered Care Focus is on the patient/resident as the center of control. Supports each resident in making his or her own choices. Includes making an effort to understand what each patient/resident is communicating, verbally and nonverbally, to identify what is important to each resident with regards to daily routines and preferred activities and having and understanding of the resident's life before coming to reside in the health care center. Under the section titled Admission Comprehensive Plan of Care revealed, number four The care plan approach serves as instructions for the patient/resident's care and provides continuity of care by all partners. Review of R42's Electronic Medical Record (EMR) revealed, she admitted with diagnoses that included but were not limited to Chronic Obstructive Pulmonary Disease (COPD), acute respiratory failure, and chronic pulmonary embolism. Review of R42's care plan revealed resident removes nasal canula, adjust settings and turns concentrator off with approaches that included but not limited to regularly check to see if tubing is properly worn with approach start date of 8/26/2024 and administer medication as ordered with approach start date of 7/15/2024; resident has episodes of shortness of breath and ineffective air exchange related to emphysema/COPD with approaches that included but not limited to administer oxygen at 2 (two) L/min (liters per minute) via nasal cannula, monitor and report signs of respiratory distress, monitor/document respiratory status every shift. (See Medication Administration Record), respiratory therapy: ipratropium-albuterol solution for nebulization; 0.5 mg (milligram)-3 mg (2.5 mg base)/3 mL (milliliters); amount: one vial with approach start date of 6/12/2024; resident has impaired gas exchange related to COPD, COPD exacerbation, and acute respiratory failure with approaches that included but not limited to administer oxygen at 2L/min via nasal cannula PRN (as needed), monitor oxygen saturation via pulse oximetry per protocol and prn, monitor/document respiratory status for changes, and provide respiratory care: nebulizer tx (treatment) per MD (medical doctor) order q (every) 12 hours, record response and time of length of time of treatment with approach start date of 6/1/2024. Review of R42's Medication Administration Record (MAR) dated 11/1/2024 through 11/20/2024 revealed, orders to monitor vital signs weekly on Wednesdays (3-11pm) once a day on Wednesday to administer oxygen at 2 LPM via nasal cannula as needed for shortness' of breath r/t (related to) COPD, check pulse ox check PRN as needed, and administer ipratropium-albuterol solution for nebulization; 0.5 mg-3 mg (2.5 mg base)/3 mL three times a day however there was no documentation on the MAR for monitoring respiratory status every shift, monitoring oxygen saturation or documentation of response and length of time for treatments. Observation on 11/17/2024 at 3:17 pm revealed, R42 receiving oxygen at 5 LPM via nasal cannula. Observation on 11/17/2024 at 5:04 pm revealed, R42 receiving oxygen at 5 LPM via nasal cannula. Observation on 11/17/2024 at 5:10 pm with Licensed Practical Nurse (LPN) DD, who was asked to R42's room confirmed the oxygen setting was at 5 LPM. Interview on 11/20/2024 at 1:50 pm with Registered Nurse (RN) EE revealed that he knew when R42 needed oxygen by checking her pulse oximetry and from signs and symptoms. He revealed that R42 did not have history of adjusting the flow rate. He revealed that he should be checking the flow rate to verify that it was correct every shift. He then stated that if a resident that receives a breathing treatment, they were supposed to be checking the vital signs before treatment and after treatment. He stated that it should be documented on the medication administration record (MAR) and/ or under the vital signs tab. He confirmed that they had not been documenting. Interview on 11/20/2024 at 1:59 pm with the Director of Health Services (DHS) revealed, breathing treatments documentation should include vital signs 15 minutes before treatment, 15 minutes post treatment and the duration of the treatment. She stated that the oxygen flow rate should be checked frequently at a regular basis, because she really does need her oxygen. Cross Reference F695

Based on observation and interviews, the facility failed to ensure that it was maintained in a safe, clean and comfortable home-like environment including dusty and warped blinds in common areas, dining room and one resident room (A 20); dusty air conditioner (AC) units in three resident rooms (rooms A 16, A 20, A 21) as well as broken face grill on AC unit in room A 16. The sample size was 28. Findings include: Observation on 6/24/18 at 3:20 p.m., revealed the blinds in the common sitting room/media room at the front of the building, were broken, warped and dusty on three of three windows. Observation on 6/24/18 at 3:30 p.m., revealed room A 16 AC unit dusty face grill and face grill had one slat broken off. Observation on 6/24/18 at 3:42 p.m., room A 20 revealed blinds on window were broken and warped to a condition that does not open to allow natural sunlight in; AC unit with dusty face grill. Observation on 6/24/18 at 3:51 p.m., revealed room A 21 AC unit with dusty face grill. Observation on 6/24/18 at 5:18 p.m., revealed the blinds in the dining room (two windows and one door) were dusty with thick layer of dust. An interview on 6/27/18 at 2:30 p.m., with the Maintenance Director revealed that housekeeping staff are supposed to dust the blinds in resident rooms and in the common areas every day. He further stated the AC units are serviced by the maintenance department, but the housekeeping staff are supposed to dust them off daily, when they clean the resident rooms. He stated he has new housekeeping staff, but they have been oriented as to their job responsibilities. He stated there is not a formal checklist for compliance or understanding about what their specific job responsibilities are. An interview on 6/27/18 at 4:03 p.m. with Housekeeping tech DD revealed that she is new and is still getting a feel of what her responsibilities are. She stated she cleans all the resident rooms, sweeping, mopping, emptying trash, cleaning bathroom, wiping walls and countertops. She stated that she wipes the blinds if they look like they need to be cleaned, but she doesn't do it everyday. She stated that she was never told to wipe the air conditioner (AC) units. An interview on 6/27/18 at 7:08 p.m. with the Administrator revealed that she has not been informed of any concerns with the environment, such as broken/warped blinds, dusty blinds in common areas, dusty AC units.

Based on observation, staff interview, and policy review, the facility failed to maintain a clean environment in the laundry room by transporting soiled laundry in the clean side of laundry, to prevent contamination; also failed to maintain environment in laundry room in a sanitary manner. The facility census was 39 residents. Findings include: Review of the facility policy titled Infection Control-Linen and Laundry Services revealed that all soiled linen should be bagged or put into carts at the location where used. Dirty linen should be clearly separated from areas where clean linen is handled. During observation of laundry services on 6/26/18 at 10:20 a.m., Laundry Aide CC was observed sorting soiled laundry wearing appropriate personal protective equipment (PPE). During this observation, Floor Tech, opened laundry room door, on the clean side of the laundry. He walked into the clean side of the laundry room carrying in his bare hands, soiled towels, that had been used to clean the meal carts in the kitchen. Laundry Aide CC spoke in a loud voice at him What are you doing? She stated to surveyor I can't believe he just did that. After observation of sorting laundry, surveyor observed Laundry Aide CC removing clean laundry from the dryer into a wire basket with wheels, labeled Clean. The Laundry Aide CC began folding clean linen from the wire basket and stacked them onto the folding table, later to be transported to linen closets on each unit. During continued observation of the laundry room, the area behind the two washing machines had multiple areas of brown, formed substance in clunks, spread over the entire floor area. There was also a darkened, mold colored fabric material wadded up in the left corner of the area. Laundry Aide CC stated she did not know what the brown material was or what the wadded fabric was, however, she stated it looked like a sheet. An interview on 6/26/18 at 7:49 a.m. with the Floor Tech, stated that he did not know that he could not walk through the clean side of the laundry to place dirty laundry items in the barrels. He stated that he does that all the time and no-one told him he couldn't. He further stated that he did not receive any training pertaining to infection control with the laundry service. An interview on 6/27/18 at 2:30 p.m. with the Maintenance Director revealed that the Floor Tech works in the laundry room every other weekend, and has been trained on infection control procedures when working in the laundry. He stated that he knows that he is not supposed to even transport dirty linen in the halls without being bagged. He stated he probably just forgot. An interview on 6/27/18 at 6:38 p.m. with the Director of Health Services (DHS) revealed that she was not aware that the Floor Tech did not know he should not take dirty laundry through the clean side of the laundry facility. She stated that she thought the Maintenance Director was responsible for doing their in-service trainings, and cannot recall if the Floor Tech had attended one of her in-services on infection control. An interview on 6/27/18 at 6:38 p.m. with the Administrator revealed that the Corporate Maintenance Director does the in-service training for the Maintenance and Housekeeping staff. She stated that the Floor Tech knows he should not transport dirty linen in the hallways without being bagged, and entering into the clean side of the laundry room with dirty linen.

Based on observation and staff interview, the facility failed to maintain two of two public water fountains in a clean and sanitary manner. The facility census was 39. Findings include: Observation on 6/24/18 at 3:22 p.m., 6/25/18 at 8:18 a.m., 6/25/18 at 4:01 p.m., 6/26/18 at 9:19 a.m., 6/26/28 at 4:33 p.m., 6/27/18 at 7:58 a.m., and 6/27/18 at 2:00 p.m., revealed that the public water fountain in the front lobby to have green slimy residue on the spigot and in the drain area. Observation on 6/24/18 at 4:18 p.m., 6/25/18 at 8:20 a.m., 6/25/18 at 4:04 p.m., 6/26/18 at 9:21 a.m., 6/26/18 at 4: 35 p.m., 6/27/18 at 8:01 a.m., and 6/27/18 at 2:03 p.m., revealed that the public water fountain on A Hall to have green slimy residue on the spigot and in the drain area; also pink material dried over the surface bowl of the fountain. An interview on 6/27/18 at 2:30 p.m. with the Maintenance Director revealed that the housekeeping staff are supposed to clean the public water fountains when they clean the public restrooms. He stated he has new housekeeping staff, but they have been oriented as to their job responsibilities. He stated there is not a formal checklist for compliance or understanding about what their specific job responsibilities are. He verified that the two public water fountains were dirty with green slimy residue on the spigot and in the drain area and the fountain on A Hall had dried pink material on the bowl of the fountain. An interview on 6/27/18 at 4:03 p.m. with Housekeeping tech DD revealed that she is new and is still getting a feel of what her responsibilities are. She stated she was not told that she was supposed to be cleaning the public water fountains every day. An interview on 6/27/18 at 7:08 p.m. with the Administrator revealed that she has not been informed of any concerns with the environment or dirty water fountains. She stated there was not any policies or procedures for cleaning the public water fountains.

Based on observation and staff interview the facility failed to ensure that the temperature of foods served to residents was held at or above the level necessary to prevent potential foodborne illnesses. This affected all residents on oral alimentation (census = 41) Findings include: During a measurement of temperatures of food items held on the steamtable and being served to residents at the lunch meal on 7/2/13 at 11:55 AM, the following items were found to be below the minimum safe temperature level of one hundred and forty degrees Fahrenheit (140 F). At that time 13 dining residents had been served and 6 room trays had been passed. : -meatloaf- 121 degrees F -fried okra-113 degrees F -mashed potatoes-138.9 degrees F -pureed okra-118 degrees F -pureed meatloaf- 105 degrees F -macaroni-130 degrees F -squash-137.8 degree F The above observation was made using the food service department's digital thermometer and was confirmed by the facility's Food Service Director.

Based on observation, staff interviews, and policy review the facility failed to ensure that non-licensed staff did not reconnect a feeding tube and/or turn on a feeding pump for one (1) resident (#10) of two (2) residents with enteral feeding tubes from a sample of thirty-one (31) residents. Findings include: Observation on 07/03/13 at 9:20 a.m. revealed two (2) Certified Nursing Assistants (CNAs) ("AA and "BB") on the A Hall bringing resident #10 to the front hall in a gerichair with the feeding pump which was disconnected from the resident and covered by a pillow case. Continued observation revealed CNA "AA" connect the resident's feeding tube, in the abdomen, with her bare hands, to the feeding pump, turn the pump on, cover the resident with a blanket and walk away. During this observation the Director of Health services (DHS) and Assistant Director of Health Services (ADHS) were standing at the nurses station. Interview with CNA "AA" on 07/03/13 at 9:25 a.m. revealed that she just finished giving resident # 10 a bed bath and that this was the second time that she had connected the resident's tube and started the pump. Continued interview revealed that she worked in the facility for many years and was taught to connect the tubing and start the pump a long time ago and did not realize that she should not touch the pump or the feeding tube. Interview with the DHS on 07/03/13 at 9:30 a.m. revealed that the CNAs were never taught to disconnect or reconnect a resident's g tube or to restart the pump. Continued interview revealed that is was her expectation that CNAs would not touch the feeding tube in any way or to start the pump. Interview with CNA "CC" on 07/03/13 at 10:40 a.m. revealed that she had worked in the facility for three 3 months and provided care for a resident on her hall that had a g- tube. Continued interview revealed that when she transfers the resident from the bed to the chair by the lift she disconnects the tube and turns off the pump, and when she is done she reconnects the feeding tubing and restarts the pump before she takes the resident to sit in the Television (TV)room. Interview with Licensed Practical Nurse (LPN) "DD" on 07/03/13 at 10:45 a.m. revealed that the CNAs know that it's a nurses duty to do anything related to the feeding tube and pump. Interview with CNA "BB" on 07/03/13 at 10: 49 a.m. revealed that when she has a resident with a feeding tube she disconnects the tube and turns off the pump herself, she does not call for the nurse to do it. Continued interview revealed that they were never told that they were not allowed to touch the feeding tube or the pump.

Based upon observation, record review and staff interviews the facility failed to ensure that call lights were in working order in two (2) rooms (55 A&B bed and 58 A&B) and four (4) beds. Findings include: Observation on 7/1/13 at 11:13 a.m. revealed that the call lights in room 55 for both A and B beds did not work. Interview on 7/2/13 at 11:45 a.m. with Maintenance Director "FF" revealed that call lights are checked daily and then the information is discussed during the daily meeting. Continued interview revealed that all call lights should be working in the building. Observation and interview on 7/2/13 at 12:10 p.m. with the Administrator and Maintenance Director revealed that the call lights for room 55 beds A and B were not working. The Maintenance Director wiggled the connections and both lights worked but only for a short time. Observations 7/2/13 beginning at 12:50 p.m. revealed, after checking all the call lights in the building, that the call lights in room 58, beds A and B, were not working consistently. The resident's in room 55 A &B and 58 A & B were capable of using the call lights.

Based on observations conducted during the medication pass , record review, and staff interview, the facility failed to ensure it was free of a medication error rate of five (5) percent or greater. Findings include: Observations conducted on 8/17/10 at 4:12 p.m. and on 8/18/10 at 8:25 a.m. and 8:36 a.m. revealed two (2) of four (4) nurses on one (1) of three (3) halls administering medications. Four (4) medication errors were observed out of fifty-four (54) opportunities. This resulted in a medication error rate of 7.14%. 1. Observation on 08/17/10 at 4:12 p.m. revealed Licensed Practical Nurse (LPN) "BB" administering 5:00 p.m. medications to resident #7. Included in the medications given to the resident was [MEDICATION NAME], used for high blood pressure. Review of the physician's orders [REDACTED]. Interview on 08/18/10 at 11:15 a.m. with the Registered Nurse (RN) Administrator revealed that if a drug was scheduled on the physician's orders [REDACTED]. 2. Observation on 08/18/10 at 8:36 a.m .revealed LPN "AA" administering 9:00 a.m. medications to resident #16. Review of the physician's orders [REDACTED]. Interview on 8/18/10 at 10:30 a.m. with LPN "AA" revealed that the medication was not given. 3. Observation on 08/18/10 at 8:25 a.m. revealed LPN "AA" administering 9:00 a.m. medications to resident #64. Review of the physician's orders [REDACTED]. These medications were not given during the medication pass. Interview on 08/18/10 at 10:30 a.m. with, LPN "AA"' revealed that she did not give the multivitamin, as it had been discontinued off the MAR indicated [REDACTED]. Interview on 8/18/10 at 10:54 a.m. with the Administrator revealed that the physician's orders [REDACTED].

Based on observation, record review, and staff interview, the facility failed to administer give (1) medication and discontinue one (1) medication as ordered for one (1) resident (#64) from a sample size of twenty-nine (29) residents. Findings include: Observation on 08/18/10 at 8:25 a.m., during medication pass with Licensed Practical Nurse (LPN) "AA" revealed mediations being administered to resident #64. Review of the physician's orders [REDACTED]. Interview on 8/18/10 at 10:30 a.m. with LPN "AA" revealed that she thought the [MEDICATION NAME] had been discontinued and replaced with [MEDICATION NAME]. The nurse was unable to find the order to do this. During continued interview, the nurse called the facility's dispensing pharmacy, and was told by the Pharmacist that an order for [REDACTED]. She stated this supply was left over from what the resident received prior to their hospitalization on [DATE] and acknowledged that there was no [MEDICATION NAME] packaged for the resident in the medication cart. Interview on 8/18/10 at 10:54 a.m. with the Registered Nurse (RN) Administrator and the Corporate Consultant "CC" revealed that when resident #64 returned from the hospital on [DATE], [MEDICATION NAME] 30 mg daily was ordered and the [MEDICATION NAME] 40 mg, which the resident received twice a day prior to the hospitalization , had been discontinued. The Corporate Consultant indicated that it appeared as though the 'L' in [MEDICATION NAME] had been written over on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview on 8/18/10 at 11:15 a.m. with LPN "AA" revealed that the resident's doctor instructed her to discontinue the [MEDICATION NAME], and give [MEDICATION NAME] 30 mg daily.