Mount Washington Care Center

Inspectors wroteBased on medical record review, observation, and staff, resident and family interview, the facility failed to ensure call lights were answered timely. This affected three (#02, #04, and #06) of five residents reviewed for care. The facility census was 69. Findings Include:1. Review of the medical record revealed Resident #02 was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease (stage four), esophageal obstruction, and hypertensive heart disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #02 was cognitively intact, had no behaviors, had not rejected care, and did not wander. During an interview and observation on 01/07/26 at 11:10 A.M., Resident #02 was cold and pushed his call light for assistance. The call light was observed activated at 11:12 A.M. and was not answered until 11:39 A.M. [...]

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure implementation of physician orders for appropriate respiratory care. This affected one (Resident #71) of three residents reviewed for respiratory care and services. The facility census was 70 residents.

Inspectors wroteBased on record review, review of a fall investigation, review of hospital records, staff interviews, and facility policy review, the facility failed to effectively manage one Resident's (#56) pain following an unwitnessed fall on 08/15/24, which subsequently resulted in a left subcapital femoral neck fracture. Actual harm occurred on 08/15/24 around 11:15 P.M. when Resident #56 had an unwitnessed fall in her room and reported left leg and knee pain to Licensed Practical Nurse (LPN) #212 and LPN #213. Resident #56 received one as needed (PRN) Tylenol but no documentation was completed on the medication administration record (MAR). The resident verbally yelled out and had facial grimacing and refused to get out of bed related to continued pain and discomfort in her left leg. The On-call Nurse Practitioner (NP) #214 ordered Resident 56 to receive a left knee x-ray and an ice pack for pain. [...]

Inspectors wroteBased on medical record review, resident and staff interviews, and policy review, the facility failed to ensure care conferences were held as required for residents and their representatives. This affected seven Residents (#02, #10, #17, #35, #36, #42 and #56) of the seven residents reviewed for care conferences. The facility census was 80.

Inspectors wroteBased on observation, staff interview and record review, the facility failed to utilize the correct transfer lifting sling for the mechanical lift, as listed in the manufacture directions. This affected one Resident (#22) but had the potential to affect 13 additional Residents (#17, #10, #15, #1, #66, #76, #233, #25, #40, #58, #23, #231 and #63) who the facility identified as being dependent on staff for transfer via mechanical lift. The facility also failed to properly assess/evaluate residents for safe smoking practices. This affected two Residents (#10 and #33) of the two residents identified as being smokers. The facility census was 80. Findings Include: 1) Review of the medical record for Resident #22 revealed the resident was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, staff interviews and record review, the facility failed to maintain a sanitary kitchen to prevent cross contamination of food. This affected 78 Residents who received food from the kitchen. The faciity identified two residents who did not receive any food from the kitchen. The facility total census was 80. Findings Include: Observation on 02/24/25 at 8:50 A.M., revealed there was a gray material blowing off of the grill of the wall fan blowing towards a table where foods were being prepared by [NAME] #180. In the dry food storage area, there were three bags of open, undated and unlabeled foods. There was an outputting air vent, three feet from foods being cooked on the stove, with a heavy buildup of grayish debris. Above the stove, the exhaust vents were noted with gray debris hanging over foods cooking on the stove. [...]

Inspectors wroteBased on observation, staff interviews and record review, the facility failed to serve meals to all residents in the dining room in a timely manner. This affected two Residents (#65 and #71) of the three residents dependent on staff in the 200-unit dining room. The facility census was 80. Findings Include: 1) Review of medical record for Resident #65, revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #65 include dementia, cerebral infarction, hemiplegia, dysphagia, anxiety disorder, restlessness and agitation. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE], revealed the resident had severely impaired cognition and was dependent on staff for meal assistance. The resident received a regular puree diet. 2) Review of the medical record for Resident #71 revealed the resident was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the Ombudsman when residents were transferred or discharged from the facility. This affected two Residents (#42 and #58) of the two residents reviewed for Ombudsman notification. The facility total census was 80. Findings Include: 1) Review of the medical record for Resident #42 revealed an admission date of 08/18/21. Diagnoses included pneumonia, type two diabetes mellitus (DM II), acute respiratory failure with hypoxia, and major depressive disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #42 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of nine. This resident was assessed to require setup with eating, partial assistance with toileting and transfers, and supervision with bathing and dressing. [...]

Inspectors wroteBased on observations, medical record review and staff interviews, the facility failed to ensure residents who were at risk for skin breakdown, had interventions implemented to prevent skin breakdown. This affected one Resident (#23) of the three residents reviewed for pressure ulcers. The facility census was 80.

Inspectors wroteBased on record review, observations, staff interviews, review of hospital records, and policy review, the facility failed to provide adequate hydration for a dependent resident. This affected one Resident (#17) of the residents reviewed for hydration. The facility also failed to adequately monitor residents weight loss/gain, notify the physician and implement interventions. This affected two Residents (#10 and #73) of the four residents reviewed for nutrition. The facility census was 80.

Inspectors wroteBased on observatoin, medical record review, staff interviews, and review of the facility policy, the facility failed to ensure insulin vials were properly labeled and stored. This affected four Residents (#09, #30, #41 and #49) of the 17 residents with medications stored in the two-center medication cart. The facility census was 80.

Inspectors wroteBased on observation, staff interview and record review, the facility failed to provide timely dental care services. This affected one Resident (#58) of one resident reviewed for dental services. The facility total census was 80. Findings Include: Record review of Resident #58 revealed the resident was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Diagnoses included hemiplegia, cerebral infarction, dysphagia, chronic obstruction pulmonary disease, diabetes, and malnutrition. Review of a physician order dated 09/01/23, revealed the resident may see dental services as needed. Review of a care conference dated 12/04/24, revealed Resident #58 requested a dental appointment to have dentures repaired. There was no documented evidence that the resident had a dental appointment since admission of 09/01/23. [...]

Inspectors wroteBased on review of the medical record, observations, staff interviews, review of online resources from the Centers for Disease Control (CDC), and policy review, the facility failed to provide appropriate infection control measures while performing incontinence care and failed to ensure enhanced barrier precautions (EBPs) were implemented and followed according to guidelines. This affected one Resident (#17) of the 17 residents reviewed for incontinence care and being on EBPs. The facility census was 80.

Inspectors wroteBased on medical record review, interview with the physician, and review of the facility policy, the facility failed to timely notify the physician when Resident #78 had abnormal vital signs during the time Resident #78 was exhibiting a change in condition and being treated for an infection. This affected one (Resident #78) of three residents reviewed for change in condition.

Inspectors wroteBased on staff interview, record review, and review of the facility's policy, the facility failed to investigate resident falls and determine the root cause of the resident's falls. This affected three (#25, #82, and #86) of three residents reviewed for falls. The facility census was 82.

Inspectors wroteBased on staff interviews, observation, record review, and review of the facility policy, the facility failed to provide timely incontinence care for a resident. This affected one (Resident #80) of three residents reviewed for incontinence care. The facility census was 82.

Inspectors wroteBased on staff interview and record review, the facility failed to have a full time qualified social worker for a facility with more than 120 beds. This had the potential to affect all 82 residents residing in the facility.

Inspectors wroteBased on medical record review and staff interview, the facility failed to coordinate care with the home health agency to ensure a smooth and safe resident discharge. This affected one (#90) of three residents reviewed for discharge planning. The facility census was 89.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a Registered Nurse was working at least 8 hours a day. This had the potential to affect all 89 residents. The census was 89.

Inspectors wroteBased on observation, interviews, and policy review the facility failed to ensure refrigerator temperatures were checked routinely, specifically refrigerators holding medications. Additionally, failed to ensure residents' refrigerated foods were properly labeled. This affected all 84 residents who reside in the facility. The facility census was 84.

Inspectors wroteBased on medical record review, staff, resident and family interview, observations, review of the staffing schedules for room assignments and policy review the facility failed to ensure residents received care and services according to the plan of care. This affected five residents (#09, #16, #37, #43 and #48) of six reviewed for activities of daily living (ADL). The facility census was 84.

Inspectors wroteBased on medical record review, observation, staff and resident interview and policy review. The facility failed to ensure medications were safely stored. This affected five residents (#08, #56, #58, #70 and #382) out of five residents reviewed. The facility census was 84. 1. Review of the medical record for Resident #70 he admitted to the facility on [DATE]. His diagnosis included essential primary hypertension, hyperlipidemia, anemia, arthritis, pressure ulcer of the left heel, and COVID-19. Review of the Minimum Data Set (MDS) assessment for Resident #70 dated 12/23/21 revealed he had intact cognition. Resident #70 was independent with eating and did not require any assistance from staff. Review of the Medication Administration Record (MAR) dated January 2022 revealed Resident #70 was ordered the following morning medications: [...]

Inspectors wroteBased on medical record review, staff interview and resident interview, observation and policy review, the facility failed to ensure residents had appropriate clothing to wear. This affected one resident (#434) of three residents (#09, #78, and #434) reviewed for dignity. The facility census was 84.

Inspectors wroteBased on medical record review, staff interview and policy review the facility failed to ensure resident advance directives were accurate. This affected one resident (#02) of three residents (#02, #09 and #49) reviewed for advance directives. The facility census was 84.

Inspectors wroteBased on observation, staff and family interview, and policy review the facility failed to maintain resident room environment in a clean, sanitary and comfortable manner. This affected three residents (#07, #25 and #48) of eight residents who resided in the seven rooms observed. The facility census was 84.

Inspectors wroteBased on record review, interview and policy review the facility failed to ensure a valid Pre-admission Screen and Resident Review (PASRR) was in place. This affected one resident (#382) out of three residents (#68, #70, and #382 residents reviewed for PASRR status. The facility census was 84.

Inspectors wroteBased on record review, interview, and policy review the facility failed to develop a baseline care plan for residents. This affected two residents (#68 and #382) of three residents reviewed for baseline care plans. The facility census was 84.

Inspectors wroteBased on medical record review, staff and resident interview and observations the facility failed to ensure residents received specialized range of motion appliances as ordered by the physician. This affected two residents (#43 and #37) of two residents reviewed for splints and palm protector placement. The facility census was 84.

Inspectors wroteBased on medical record review, staff and resident interview, observation and review of the incident report the facility failed to ensure an intravenous (IV) catheter was initiated on the correct resident. This affected one resident (#50) of two residents reviewed for intravenous fluid. The facility census was 84.

Inspectors wroteBased on medical record review, staff interview and observations the facility failed to monitor for adverse side effects for residents receiving psychotropic medications. This affected one resident (#57) of five residents reviewed for unnecessary medication. The facility census is 84.

Inspectors wroteBased on medical record review, staff interview and observations the facility failed to ensure residents receiving as needed psychotropic medications was limited to 14 days and not continued unless the prescribing physician evaluated the appropriateness of the medication. This affected one resident (#57) of five residents reviewed for unnecessary medication. The facility census is 84.

Inspectors wroteBased on medical record review, staff interview, observations, and policy review the facility failed to ensure staff was available to assist dependent residents with eating after meals trays were delivered to resident rooms. This affected one resident (#36) of four reviewed for dependent residents requiring meal assistance. The facility census was 84.

Inspectors wroteBased on medical record review, observation, staff interview and policy review the facility failed to ensure a resident food preferences were accommodated. This affected one resident (#15) of three residents reviewed for meal preferences. The facility census was 84.

Inspectors wroteBased on medical record review, observation and staff interview the facility failed to provide each resident with a therapeutic diet as ordered by their physician. This affected one resident (#54) of three residents reviewed for nutrition.

Inspectors wroteBased on medical record review, staff and resident interview and policy review, the facility failed to ensure when a resident formulated an advanced directive, the information regarding the advanced directive was accurate in all areas where advanced directive information was included in the medical record. This affected one (#107) out of 24 residents reviewed for Advanced Directives. The facility census was 123.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to implement one resident's plan of care to prevent potential elopement from the facility. This affected one (#20) out of two resident reviewed for Accidents. The facility census was 123.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to implement one resident's plan of care to prevent potential elopement from the facility. This affected one (#20) out of two resident reviewed for Accidents. The facility census was 123.