Ware Memorial Care Center

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #1) of 6 residents reviewed for medication administration. The facility failed to ensure LVN A stayed with Resident #1 until the medications she gave him were taken on the morning of 04/16/26. This failure could place residents at risk of harm due to not receiving necessary medications or receiving medications at the wrong time as well as taking medication that does not belong to them. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an assessment accurately reflected a resident's status for 4 (Resident #1, #2, #28, and #40) of 24 residents reviewed for accuracy of MDS assessments. -The facility failed to accurately assess Resident #1, #2, and #40 for the use of restraints on their MDS assessments. -The facility failed to accurately assess Resident #28 for the use of CPAP therapy on his MDS assessment. This failure to accurately assess a resident could place residents at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 2 (Resident #46 and Resident #79) of 24 residents reviewed for medication administration.1. The facility failed to ensure LVN A stayed with Resident #46 until her medications were swallowed on the morning of [DATE].2. The facility failed to ensure LVN B stayed with Resident #79 until her medications were swallowed on the morning of [DATE].3. The facility failed to ensure the Southeast Hall medication cart did not contain expired eyedrops.4. The facility failed to ensure the Southwest Hall medication cart did not contain expired insulin. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 2 kitchens when they failed to: Ensure kitchen staff used proper hand washing and sanitation procedures when handling food. Ensure kitchen staff and other employees wore hair restraints and beard coverings while in the kitchen. This failure could cause decreased meal satisfaction and decreased meal consumption due to using unsanitary practices in the facility's kitchen and could affect all residents in the facility that receive meals from the facility kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 1 (Resident #55) of 25 residents reviewed for advanced directives. Resident #55's DNR form lacked a dated notarial acknowledgment and therefore was not fully executed. This failure could place residents at risk of receiving medical treatment inconsistent with their or their legal representative's expressed wishes.

Inspectors wroteBased on observation, interview, and record review; the facility failed to ensure medications were stored in accordance with currently accepted professional principles for 1 (the 1-Northwest Hall medication cart) of 10 medication storage areas reviewed for medication storage. -The 1-Northwest Hall medication cart has loose medication pills. The facility's failure could result in a resident receiving medications that would be ineffective for their treatment resulting in exacerbation of the resident's condition and disease processes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #11) of 4 residents observed for infection control. -LVN E did not perform hand hygiene properly while performing wound care for Resident #11. This deficient practice has the potential to affect residents by exposing them to care that could lead to the spread of infections, tissue breakdown, and feelings of isolation related to poor hygiene.

Inspectors wroteBased on interview and record review the facility failed to, within 7 days after completing a resident's assessment, encode the following information for each resident in the facility: A subset of items upon a resident's transfer, reentry, discharge, and death for 3 (Resident #49, Resident #53, and Resident #60) of 21 residents reviewed for assessments.1. The facility failed to encode a death in facility assessment for Resident #49 within 7 days of his death in the facility on [DATE].2. The facility failed to encode a discharge assessment for Resident #53 within 7 days of his discharge on [DATE].3. The facility failed to encode a death in facility assessment for Resident #60 within 7 days of her death in the facility on [DATE]. These failures could place residents at risk of inaccurate medical records. Findings Included:1. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents receive care consistent with professional standards of practice, to prevent pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and once developed, failed to ensure necessary treatment and services to promote healing for one (Resident #1) of nine residents reviewed for pressure ulcers. The facility failed to: A. Ensure Resident #1 who was admitted to the facility without a pressure ulcer did not develop an unstageable pressure ulcer with eschar (a layer of dead skin tissue that forms over a wound) on her coccyx within two weeks of admission. B. Failed to notify the wound care nurse of the ulcer. C. Failed to accurately document Resident #1's skin conditions which caused delayed care for the ulcer. D. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 7 out of 8 resident snack refrigerators located in the residents dining rooms, reviewed for kitchen sanitation. 1. The facility failed to ensure food items were properly stored, labeled, and dated. 2. The facility failed to ensure refrigerators were free of expired foods, non-food items and staff items. 3. The facility failed to ensure cleanliness was maintained in the refrigerators. These failures could place residents who ate food served by the kitchen, and stored food in the resident refrigerators were at risk of food-borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had the right to be informed in advance if the risks and benefits of proposed care, or treatment and treatment alternatives or treatment options and to chose the alternative or options he or she prefers for 5 of 19 residents (Resident #13, #15, #47, #70, and #75) and 5 residents interviewed during an anonymous interview reviewed for self-determination. The facility failed to ensure Resident #13, #15, #47, #70, and #75 and 5 anonymous residents received requested bedrails for 10 days or more after requested by the resident or family. This failure could cause residents to feel uncomfortable and disrespected leading to feeling of anxiety, anger, isolation, and deterioration in general health conditions.

Inspectors wroteBased on interview and record review the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of charges for those services, which included charges for services not covered under Medicare/Medicaid or by the facility's per diem rate for 3 of 3 residents (Resident #31, Resident #82, and Resident #240) reviewed for Medicare/Medicaid coverage. 1. The facility failed to ensure Resident #31, Resident #82, and Resident #240 were given a NOMNC (a notice that indicates when care is set to end from a home health agency, skilled nursing facility, comprehensive outpatient rehabilitation facility, or hospice) with information on how to appeal the decision when residents were discharged from skilled services prior to covered days being exhausted. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an assessment accurately reflected a resident's status for 1 of 19 residents (Resident #1) reviewed for accuracy of MDS assessments. -The facility failed to accurately assess Resident #1 who was listed for having a urinary catheter on her 9-3-2024 quarterly MDS. This failure to accurately assess a resident could place residents at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 2 (Resident #6 and Resident #79) of 5 residents reviewed for respiratory care. The facility failed to change nebulizer tubing for Resident #6 for 4 months. The facility failed to change nebulizer tubing for Resident #79 for 6 months. This failure could affect residents on respiratory therapy by placing them at risk for respiratory compromise and associated complications such as shortness of breath, confusion, respiratory failure, and exacerbation of their condition.

Inspectors wroteBased on observation, interview, and record review; the facility failed to provide pharmaceutical services that included the accurate acquiring and dispensing of all drugs and biologicals to meet the needs of each resident for 1 (Resident #75) of 19 residents reviewed for medication therapy and 2 (the Rehabilitation and Long-Term Care medication room and the 1-North medication room) of 8 medication storage areas reviewed for medication storage. -LVN B left the morning medications with Resident #75 unattended and did not verify if Resident #75 took the AM medications. -the Rehabilitation and Long-Term Care medication room had an expired OTC medication. -the 1-North medication room had an expired OTC medication. [...]

Inspectors wroteBased on observation, interview, and record review; the facility failed to store a controlled drug subject to abuse properly for 1 (the Rehabilitation and Long-Term Care medication room) of 8 medication storage areas reviewed for medication storage. The Rehabilitation and Long-Term Care medication room had a Schedule III narcotic stored improperly in the refrigerator. The facility's failure to ensure medications were stored properly could result in medication diversion leading to a resident not receiving ordered treatment affecting the resident's treatment and care leading to deterioration in their health.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete, accurate, readily accessible, and systemically organized records for 1 (Resident #1) of 8 residents reviewed for medical records. The facility failed to document the fall risk evaluation for Resident #1's history of falls within the last 90 days. This failure could place all residents at risk of not receiving appropriate care through inadequate documentation possibly resulting in deterioration in condition, exacerbation of disease process, and increased risk of harm or injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen when they failed to: A. Ensure stored food was properly labeled, dated, and stored. These failures placed all residents who ate food served by the kitchen at risk of food-borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail for 7 (Residents #4, #6, #10, #17, #19, #23, and #61) of 18 residents reviewed for bed rails. The facility placed bed rails on the beds of Residents #4, #6, #10, #17, #19, #23, and #61 on the day the residents were admitted without attempting other interventions first. This failure could place residents at risk of entrapment or injury due to bed rails.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident had a right to reside and receive services in the facility with reasonable accommodation of the residents needs and preferences for 1 of 18 residents (Resident #23) reviewed for accommodation of needs. Resident #23's call light was not within her reach. The call light's cord was wrapped around the bed rail and was placed at the top of the bed rail out of reach and sight of resident. This failure could place residents at risk of not having their needs met and a decline in their quality of care and life.

Inspectors wroteBased on interview, and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 1 (Resident #61) of 18 residents reviewed for DNR orders. Resident #61 had an Out-of-Hospital DNR order that was invalid, as the date of signature of the Physician, Medical Power of Attorney and Notary did not match. This failure could place residents with DNR orders at risk for receiving, or not receiving, life-saving measures that align with their medical preferences.

Inspectors wroteBased on observation, interviews and record review the facility failed to provide a homelike environment, which allowed comfortable temperature levels for 3 of 5 residents in a confidential group interview. The facility failed to maintain comfortable temperature levels between 71 degrees and 81 degrees in 1 of 4 dining rooms at the facility. This failure could place residents at risk of an uncomfortable environment and diminish their quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident's assessment accurately reflected the resident's status for 1 (Resident #19) of 18 residents reviewed for accurate assessments. The facility failed to correctly code bed rails for Resident#19. The facility had bed rails incorrectly coded as restraints on the MDS Assessments of Resident #19. This failure could place residents at risk of receiving inaccurate/unnecessary levels of care.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 2 of 3 Medication Carts and one Treatment Cart. [DATE] at 8:59AM on Second floor NW Medication Cart, 3 loose medications were found in the second drawer of the Medication Cart 1 expired medication found in Treatment Cart located on the first floor NW Hall, in a room labeled 'Linen Closet.' 1 vial Insulin found open with no expiration date on Medication Cart #2 second floor SW Hall. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 25 resident (Resident #232) reviewed for infection control. 1. The facility failed to ensure that contact precaution signage was in place for Resident #232 who was positive for C-diff upon admission. 2. The facility failed to implement isolation precautions for a Resident #232 who was positive for C-Diff. This failure could place the residents at an increased risk for potentially exposing them to infections, which could lead to abdominal cramping, lethargy, increased risk for diarrhea, dehydration, and feelings of isolation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the residents environment remained as free from accident hazards as was possible; and that each resident received adequate supervision to prevent accident hazards for one resident (Resident #1) of 7 residents observed for accident hazards. -CNA A transferred Resident #1 in an unsafe manner resulting in a small skin tear and a large bruise to her left lower leg. This failure could affect all the residents at the facility by placing them at risk for accidents that lead to injuries such as bruising, skin tears, fractures, subdural hematomas, and feeling of isolation.