Bonaventure of Lacey

Facility failed to ensure appropriate care and services were implemented for two residents following changes in condition, resulting in delayed treatment/discomfort for one and multiple falls with injuries/health decline for the other.

Facility failed to complete ongoing assessments focused on identified problems, changes of condition, and when residents had injuries requiring practitioner intervention.

Facility failed to protect residents from harm and physical altercations. Specifically, two residents (R1 and R2) were subjected to physical abuse by another resident on multiple occasions, causing psychological harm and posing a risk to others in the memory care unit.

Facility failed to report incidents of physical abuse/altercations involving residents to law enforcement as required by regulations.

The licensee failed to ensure that residents were protected from harm and physical altercations for two residents, resulting in abuse and psychological harm.

The licensee failed to ensure appropriate care and services were implemented for two residents experiencing a change of condition, resulting in pain/discomfort for one and multiple falls for the other.

Facility failed to follow prescribed medication orders for 1 resident, failed to implement a safe medication system for 2 of 3 residents, and permitted untrained staff to administer medications, resulting in unaccounted narcotics and medication errors.

Facility failed to investigate, document, and report an occurrence for R4 who sustained a significant injury (tibia fracture) after a wheelchair accident, failing to determine the circumstances of the event or institute protective measures.

Facility failed to monitor residents' well-being and take appropriate actions for 2 of 4 sampled residents (Resident 2 and 4), placing them at risk for unmet care needs and lack of response to condition changes.

Facility failed to maintain accurate medication counts, ensure appropriate medication administration per physician orders for R5, and maintain complete and accurate narcotic logs for R1 and R2.

Failed to follow prescribed medication orders for one resident and failed to implement a safe medication system for two residents. Resulted in medication errors, unaccounted narcotics, and risk of injury.

Failed to investigate and document actions and findings for an incident resulting in significant injury to a resident.

Power strip plugged into another power strip in 1st floor alarm control room.

Electrical conduit not patched in back right corner of electrical room across from room 320; Food services Director's office has missing ceiling tiles.

Fire extinguisher in outside elevator room by memory care last monthly inspected in August 2024.

Facility failed to provide monthly 30 second inspection report for exit signs and emergency lights.

Facility failed to provide annual inspection report for generator.

Memory care Director's Office has an electrical outlet with a broken ground.

Extension cord being used in salon room.

Fire sprinkler heads in kitchen food prep area are loaded with debris.

Exit sign on 4th floor between room 402 and 403 failed to illuminate when tested.

Facility failed to provide annual 1.5 hour inspection report for exit signs and emergency lights.

Memory care janitor closets by room 115 and 101 failed to latch.

Dry system #1 accelerator not working as intended, valve was turned off. The air compressor for the dry system trips the electrical breaker it is plugged into, posing a fire or electrical hazard.

The facility failed to ensure medication carts were locked and secure, placing 64 residents at risk for access by unauthorized personnel.