Warr Acres Nursing Center

In the surveyor’s words

From the most serious findings on record at Warr Acres Nursing Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF558Jan 24, 2024

  Based on observation, record review and interview, the facility failed to ensure: a. the call light was in reach for two (#2 and #41) of 24 sampled residents observed during initial pool; and b. a resident's bed was positioned to allow them to watch TV comfortably for one (#41) of three sampled residents reviewed for accommodation of needs. The Executive Director identified 50 residents resided in the facility. Findings: A Facility Accommodation of Needs policy, dated 02/23, read in part, .The facility will make reasonable accommodations to individualize the resident's physical environment including their personal bathroom and bedroom .Based on individual needs and preferences, the facility will assist the resident in maintaining and/or achieving independent functioning, dignity, and well… […]

• No harm, potential for more than minimal, patternF565Jan 24, 2024

  Based on record review and interview, the facility failed to allow the resident council to meet without staff present. The Executive Director identified 50 residents resided in the facility. Findings: Documents titled Resident Council Minutes identified staff as present for the following dates: 12/06/22, 01/26/23, 03/22/23, 04/24/23, 05/23/23, 06/08/23, 07/18/23, 08/24/23, 09/13/23, 10/10/23, 11/15/23, and 12/12/23. On 01/03/24 at 2:46 p.m., the Resident Council Representative stated they had been told a staff member had to be present at all council meetings. On 01/03/24 at 3:03 p.m., the Activities Director stated the facility wanted a staff member present at all council meetings. […]

• No harm, potential for more than minimal, patternF755Jan 24, 2024

  Based on observation, record review and interview, the facility failed to ensure blood pressure and pulse were monitored as ordered for three (#7, 23, and #36) of six residents observed during medication administration. The Executive Director identified 50 residents resided in the facility. Findings: 1. Resident #7 had diagnoses which included Alzheimer's disease, anxiety disorder, hypertension, and GERD. A Physician Order, dated 09/01/22, documented lanoxin 125 mcg give one tablet by mouth one time a day for Afib, hold if pulse was below 60. […]

• No harm, potential for more than minimal, patternF759Jan 24, 2024

  Based on observation, record review and interview, the facility failed to ensure the medication error rate was less than 5%. A total of 27 opportunities were observed with three errors. The total medication error rate was 11.11%. The Executive Director identified 50 residents resided in the facility. Findings: Resident #7 had diagnoses which included Alzheimer's disease, anxiety disorder, hypertension, and GERD. A Physician's Order, dated 01/14/22, documented may crush tablets and/or open capsules unless contraindicated. A Physician's Order, dated 04/17/23, documented suction oropharynx every one hour as needed for aspiration. A Physician's Order, dated 06/14/23, documented regular diet, pureed texture, nectar (mildly thick) consistency, related to Alzheimer's disease. […]

• No harm, potential for more than minimal, patternF812Jan 24, 2024

  Based on observation, record review and interview, the facility failed to ensure food items were properly dated and labeled in the walk in cooler and refrigerator located in the kitchen. The Executive Director identified 50 residents resided in the facility. Findings: The facility Food Receiving and Storage policy, revised 12/08, read in part, .Food shall be received and stored in a manner that complies with safe food handling practices .All foods stored in the refrigerator or freezer will be covered, labeled and dated . On 01/02/24 at 1:05 p.m., Cook #1 stated staff should date and label all food items. On 01/02/24 at 1:19 p.m., the following items were observed in the refrigerator next to the tray line: a. […]