Mt Baker Care Center

Inspectors wroteBased on interview and record review the facility failed to ensure their abuse and neglect policy was followed for an allegation of abuse for 1 of 1 resident (Resident 1). This failed practice placed Resident 1 and all other residents at risk of abuse and neglect.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 3 residents (Resident 1) received the necessary care and services to attain or maintain the highest practicable physical level of well-being. Failure to ensure Resident 1 received care in accordance with a physician order and their care plan when they received a bath and not a shower. This failure potentially placed the resident at risk of medical complications and a decreased or diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 5 residents (Resident 45) reviewed for unnecessary medications, were free from unnecessary psychotropic medication (a drug that affects brain activities associated with mental processes and behavior). Failure to provide a valid diagnosis for the use of psychotropic medications placed residents at risk for receiving unnecessary psychotropic medications, for adverse events and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop comprehensive care plans to reflect the resident's current medical status and/or to include all provided nursing services for 1 of 1 resident (Resident 54) reviewed for edema management, 1 of 2 residents (Resident 5) reviewed for discharge planning, and 1 of 2 residents (Resident 15) reviewed for dementia care. This failure placed residents at risk of not receiving needed care, decline in condition, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1 of 3 residents (Resident 15) reviewed for Pressure Ulcers (PU), were provided care planned interventions they required for the prevention of a PU. This failure to implement pressure reducing interventions in accordance with physician's orders placed residents at risk for PU development, pain and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 3 of 3 residents (Residents 17, 54 and 160) were free of unnecessary drugs due to lack of monitoring and care planning of high-risk medications, including lack of assessment for anti-coagulant (blood thinning medication) use and edema (accumulation of fluid in the body) monitoring. These failures could result in unrecognized change in condition for Resident 54 related to lack of edema monitoring and Resident's 17 and 160 experiencing unrecognized signs and symptoms of bleeding while receiving an anti-coagulant medication and placed all residents at risk for adverse effects of high-risk medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff were following established guidelines related to Enhanced Barrier Precautions (EBP), which are infection control interventions designed to reduce the transmission of multi-drug-resistant organisms in healthcare settings, for 1 of 3 residents (Resident 19) reviewed for pressure ulcers. These failures placed residents and staff at risk for potential infection from cross contamination of infectious organisms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with activities of daily living to include personal hygiene and bathing for 5 of 5 sampled dependent residents (Residents 7, 9, 11, 49 and 10) reviewed for activities of daily living (ADL's). Facility failure to provide resident's, who were dependent on staff for assistance with hygiene including oral care, and showers placed residents and others at risk for embarrassment, poor hygiene, unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to identify a significant change in status for 1 of 1 sampled resident (Resident 22), reviewed for Hospice services. Failure to identify and complete a Significant Change in Status assessment, according to the Resident Assessment Instrument (RAI - consists of three basic components: The Minimum Data Set, the Care Area Assessment process, and the RAI Utilization Guidelines. The utilization of the three components of the RAI yields information about a resident's functional status, strengths, weaknesses, and preferences, as well as offering guidance on further assessment once problems have been identified). manual, placed residents at risk for inadequate care planning and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement comprehensive person-centered care plans for 1 of 2 sampled residents (Resident 42) reviewed for urinary catheters (tube inserted into the bladder to remove urine), 1 of 4 sampled residents (Resident 22) reviewed for non-pressure skin alterations, and 1 of 5 sampled residents (Resident 49) reviewed for unnecessary medications. This failure to ensure the comprehensive care plan was implemented placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to comprehensively assess, monitor, and implement dietary interventions as needed to prevent weight loss for 1 of 2 residents (Resident 49) reviewed for nutritional status. This failure placed residents at risk for continued weight loss, dehydration, and a decline in their nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were trauma survivors and diagnosed with Post Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event that was either experienced or witnessed) received culturally competent, trauma-informed care and services in accordance with professional standards of practice for 2 of 2 sampled residents (Resident 9 and 15) reviewed for Trauma informed care. The facility's failure to develop and implement resident centered interventions placed residents at risk for unidentified triggers, re-traumatization, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control standards were followed during 1 of 2 residents (Resident 45) wound care observations when hand hygiene was not completed between glove changes and when items were touched in a drawer and gloves were not changed. This failure placed residents at risk for an infection of their wound.

Inspectors wroteBased on interview, and record review, the facility failed to ensure they were free of significant medication errors for 1 of 3 sampled residents (Resident 1). The facility administered two doses of an antibiotic listed on Resident 1's allergy list. This failure placed Resident 1 at an increased risk of an allergic reaction to the medication, potential complications, and placed other residents at risk of medication errors.

Inspectors wroteBased on interview, and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 sampled residents (Resident 1) reviewed for quality of care. The facility failed to ensure Resident 1's oxygen (O2) was replaced on the resident after completion of cares. This failure resulted in Resident 1 becoming hypoxic (absence of enough air in the tissues to sustain bodily functions) and placed other residents with orders for O2 at risk for hypoxia, medical complications, and a diminished quality of life.

Inspectors wroteBased on interviews, personnel record review, and facility job description review, the facility failed to ensure Staff C, Dietary Manager (DM), was qualified with the appropriate competencies and skill sets to serve as the Director of Food and Nutrition Services. This had the potential to affect all 57 residents who consumed food from the kitchen.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure cold food was stored at the proper temperature; cold food was covered during storage; cold food was held at proper temperature for meal service; and the stove hood was cleaned in accordance with professional standards for food service safety. This had the potential to affect all 57 residents who consumed food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess one of five residents (9) whose Minimum Data Sets (MDS) Assessment (a tool used to identify a resident's care needs) was reviewed. Failure to ensure accurate assessments regarding dental/oral status placed residents at risk for unidentified and/or unmet care needs.

Inspectors wroteBased on observation, interview, and review of the manufacturer's instructions for prefilled insulin syringes, the facility failed to ensure the correct procedure was followed as directed prior to administering insulin via a prefilled syringe for one of two residents (314) observed during medication pass who received insulin. This had the potential for the resident not to receive the correct amount of insulin needed in order to control blood sugars.

Inspectors wroteF791 Based on interview, observation, and record review, the facility failed to ensure timely dental services were provided for one of one resident (9) reviewed for dental care and services. This failure placed the resident at risk for pain and a diminished quality of life. RESIDENT 9 Resident 9 admitted to the facility on [DATE] with diagnoses to include COPD (Chronic Obstructive Pulmonary Disease) and tracheostomy (tube placed into windpipe to help a person breath). Review of the Annual MDS Assessment (a tool used to identify a resident's care needs) dated 09/29/2022, showed no Obvious or likely cavity or broken natural teeth. In an interview and observation on 01/04/2023 at 2:25 PM, the resident was observed to have missing lower teeth with areas of observable broken teeth along lower front gum line. [...]