Washington Care Center

Inspectors wroteBased on interview and record review, the facility failed to complete the appropriate transfer notifications for 7 of 7 residents (Residents 1, 5, 11, 8, 23, 4, & 105) reviewed for hospitalization. The failure to offer bed holds (Residents 1, 5, 11, 8, 23, & 4), provide a written transfer notice (Residents 1, 5, 11, 8, 23, 4, & 105), and notify the State Long Term Care Ombudsman (LTCO) timely of resident discharges (Residents 1, 8 & 23) placed residents at risk for a disruption in their continuity of care, an undesired room change upon readmission, and not having the opportunity to make informed decisions about their transfer/discharge rights, and inappropriate transfers.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or their representatives were informed of the nature and implications of entering into a binding Arbitration (a procedure used to settle a dispute using an independent person mutually agreed upon by both parties) Agreement (AA) for 3 of 3 residents (Residents 1, 33, & 101) reviewed for arbitration. The facility failed to ensure the arbitration agreement was signed and accepted by the residents and/or their Durable Power of Attorney (DPOA) for financial affairs as required. These failures placed residents at risk of lacking understanding of the legal document signed, forfeiture (loss or giving up of something) of their right to a jury or court trial, and a diminished quality of life.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide care and services in a manner that maintained residents rights for 2 of 5 sampled residents (Resident 23 and 25) and 1 supplementary resident (Resident 7) reviewed for consents and unnecessary medications. This failure placed residents at risk of diminished self-worth and overall well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or their representatives received written information of their right to accept or refuse treatment by formulating an Advance Directive (AD) for 2 (Resident 23 and 105) of 6 sampled residents. This failure placed residents at risk of being denied their right to make health care decisions and preventing them from exercising their right to refuse care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure walls, heaters and baseboard in resident rooms were maintained in a safe, clean and homelike condition for 6 of 13 residents (Resident 113, 99, 25, 9, 61 & 23) , failed to ensure privacy curtains were maintained in a clean sanitary condition (Residents 113 & 9) and failed to ensure resident rooms were personalized (Resident 23). These failures left residents at risk for a less than homelike environment and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure Preadmission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment) assessment was accurate to reflect the mental health conditions for 4 of 5 residents (Resident 5, 6, 11, & 23) reviewed for PASRR/Unnecessary Medications. This failure placed residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Care Plans (CPs) were updated and/or revised as needed for 4 (Residents 10, 79, 23, & 5) of 25 sample residents reviewed. Failure to ensure CPs were updated to reflect current care needs left residents at risk for unmet care needs, delay in treatments, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure: Physician's Orders (POs) were clarified and followed for 4 (Residents 11, 25, 120, & 23) of 25 sample residents; nurses did not document nonpharmacological interventions for pain medications for 1 (Resident 23); staff did not follow the oxygen orders, the facility Bowel Movement (BM) protocol and pain medication parameters as ordered for 1 (Resident 11); and devices in place without physician order for 1 (Resident 120) of 25 sample residents. These failures placed residents at risk for medication errors, delayed treatment, Resident Rights, adverse outcomes and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to offer and provide assistance with Activities of Daily Living (ADL) for 2 of 7 residents (Residents 23 & 79) reviewed who were dependent on staff for daily cares/ADLs. The failure to provide assistance with ADLs placed residents at risk for poor hygiene, diminished feeling of self-worth, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' environment was free of accident hazards by implementing their system for screening and storing hazardous toxic chemicals in 1 of 4 soiled utility rooms (2 [NAME] Soiled Utility Room) and 1 of 4 clean utility rooms (2 East Clean Utility Room), and 1 of 4 linen rooms (2 [NAME] Clean Linen Room) reviewed. This failure placed residents at risk of injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to appropriately use Personal Protective Equipment (PPE) in accordance with Enhanced Barrier Precautions (EBP - infection control measures used to reduce the spread of multidrug-resistant organisms) for 2 supplemental residents (Residents 28 & 10) who required EBP reviewed for infection control. These failures placed residents at risk for the development and transmission of communicable diseases and an unclean environment.

Inspectors wroteBased on interview and record review the facility failed to implement an Antibiotic (ABO) Stewardship program to promote appropriate use of ABO and reduce the risk of unnecessary ABO use for 2 of 3 residents (Resident 8 & 4) reviewed for unnecessary antibiotics. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate/unnecessary use of ABOs and placed residents at a greater risk of developing ABO resistance.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each resident received assessed level of supervision and assistance to prevent accidents for 1 of 4 sampled residents (Resident 1) reviewed. Resident 1 experienced harm when they fell out of a mechanical lift without the assessed two caregiver assistance, landed on the floor, and sustained a traumatic brain injury (TBI), with multiple areas of bleeding in the brain, upper neck fracture and facial fractures. This failure placed other resident at risk that required assistance of two care givers and a mechanical lift for their Activities of Daily Living (ADLs). The admission Minimum Data Set (MDS-an assessment tool) dated 02/06/2025, Resident 1 required total assistance from staff with all ADLs including Hoyer (mechanical lift) transfers. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each resident received assessed level of supervision and assistance to prevent accidents for 1 of 5 sampled residents (Resident 1) reviewed. Resident 1 experienced harm when they rolled off the bed when they were repositioned without the assessed two caregiver assistance, landed on the floor, and sustained three fractures to their hip, knee, and back, and required an increase in pain medications. This failure placed other resident at risk that required assistance with Activities of Daily Living (ADLs). The facility's Abuse Prohibition and Prevention policy updated November 2016, showed the facility complied with Federal and State Requirements by training, protecting, and preventing abuse and neglect. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain infection control practices necessary to provide a safe and sanitary environment and prevent transmission of communicable diseases by having Personal Protective Equipment (PPE) available to staff for 12 of 19 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10,11, &12) observed requiring Enhanced Barrier Precautions (EBP) with specific diagnoses including wounds and indwelling medical devices. The facility failed to ensure alcohol-based hand sanitizer dispensers were properly functioning for 25 of 46 rooms (Rooms 202, 203, 204, 209,211, 208, 215, 216, & 218; and outside rooms 219, 250, 251, 252, 255, 256, 257, 263, 264, 265, 266, 267, 268,270, 273, & 274) observed inside and along the hallway outside occupied resident rooms. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were provided informed consent for treatments (ensuring an explanation of the risks and benefits was provided) for 3 of 5 (Residents 113, 21, & 17) residents whose medication regimen was reviewed. The failure to provide informed consent placed residents at risk for unwanted adverse side effects, unwanted treatment, and loss of autonomy.

Inspectors wroteBased on observation and interview, the facility failed to ensure the facility maintained a homelike environment for 2 of 4 units, and 1 of 1 entry way. The failure to ensure resident rooms were free of wall scrapes, stained doors and walls, damaged flooring, damaged closet doors, missing/damaged ceiling tiles, and dirty privacy curtains, and the failure to ensure the entry way was in good condition, placed residents at risk for a less than homelike environment, frustration, and a diminished sense of self-worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure a system by which residents received required written notices at the time of transfer/discharge, or as soon as practicable for 5 (Residents 127, 34, 113, 55, & 96) of 7 residents reviewed for hospitalizations. Failure to provide written notification to the resident and/or the resident's representative of the reasons for the discharge in writing and in a language and manner they understood, placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care and preferences.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level II comprehensive evaluations were obtained for 3 (Residents 134, 85, & 113) of 7 sampled residents reviewed for PASRR evaluations. This failure placed residents at risk for not receiving necessary mental health care and services.

Inspectors wrote<Resident 113> According to the 07/18/2024 Quarterly MDS, Resident 113 had medically complex conditions including anxiety, depression, and opioid dependence. The MDS showed Resident 113 took antipsychotic, and antidepressant medications. Review of the physician's orders showed Resident 113 currently took two antidepressant medications and an antipsychotic medication from 03/28/2024 until discontinued on 07/25/2024. The indication for the antipsychotic medication was for auditory hallucinations. Review of the comprehensive Care Plan (CP) showed Resident 113 had a Target Behavior due to Psychosis CP. This CP included a goal for staff to assist Resident 113 with daily episodes of psychosis. Review of the 03/13/2024 Level I PASRR indicated Resident 113 had a mood disorder and an anxiety disorder. [...]

Inspectors wrote< Resident 55> According to the 06/21/2024 Quarterly MDS, Resident 55 had significant weight loss in the last six months and was not on prescribed weight loss regimen. The MDS showed Resident 55 required maximal assistance from staff with oral hygiene, eating, and toileting needs. Review of Resident 55's record showed Resident 55's weight on 01/04/2024 was 260 pounds and on 05/28/2024 was down to 221 pounds, representing a weight loss of 39 pounds in four months. Review of Resident 55's CP showed no documentation related to weight loss or any interventions for staff to follow. In an interview on 08/20/2024 at 2:17 PM, Staff H (Dietitian) stated they were aware of Resident 55's significant weight loss. Staff H stated Resident 55's CP should be updated accordingly. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADL), related to cleanliness and grooming for 7 (Residents 21,55, 99, 134, 10, 150, & 71) of 10 sample residents reviewed for ADLs. Facility failure to provide residents who were dependent on staff for assistance with oral care, showers, getting out of bed, dressing, shaving, and nail care, placed the residents at risk for poor hygiene, greasy hair, long facial hair, embarrassment and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 (Resident 55) of 5 residents reviewed for Pressure Ulcers (PU's) received the necessary treatment and services, consistent with professional standards of practice, to promote healing, and prevent new ulcers from developing. Failure of the facility to consistently complete weekly skin assessments, assess skin integrity to identify PUs timely, ensure air mattress settings were appropriate according to resident's weight, repositioning in bed, update the Care Plan (CP) with Resident 55's refusals, and to follow the CP, placed Resident 55 at risk to develop a new PU, and diminished quality of life

Inspectors wroteBased on observation, interview, and record review facility failed to maintain and environment that was free from accident hazards. The failure to: ensure appropriate supervision and storage of smoking materials for 1 of 2 sample residents (Resident 113) and 5 supplemental (Residents 135, 117, 54, 43, & 22) residents who smoked; failed to secure chemicals in 2 of 4 clean utility rooms; and failed to secure sharps in 1 of 4 clean utility rooms, placed residents at risk for smoking related injuries, accident hazards, and diminished safety.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain infection control practices that provide a safe and sanitary environment to help prevent the transmission of communicable diseases. The facility failed to: 1) perform Hand Hygiene (HH) during resident care and during dining service; 2) ensure staff used Personal Protective Equipment (PPE) for residents reviewed for Transmission Based Precautions (TBP); 3) identify and initiate Enhanced Barrier Precautions (EBP) for residents who required EBP precautions; 4) ensure staff disposed of contaminated gloves before entering the hallway. These failures placed residents at risk for the development and transmission of communicable diseases and related complications.

Inspectors wroteBased on interview and record review, the facility failed to provide the resident and/or the resident's representative a written notice of the facility's bed-hold policy, at the time of transfer or within 24 hours, for 4 of 7 sample residents (Resident 127, 34, 55, & 96) reviewed for hospitalization. This failure placed the residents and/or their representatives at risk of not being informed of their right to, or the cost of, holding the resident's bed while hospitalized that was necessary for decision-making.

Inspectors wrote<Signing For Tasks Not Completed> <Resident 10> Observations on 08/15/2024 at 8:58 AM showed Resident 10 with a pain medication patch on the top of their right ankle. This patch had a handwritten date of, 8/14. On 08/16/2024 at 8:42 AM, this same patch remained on Resident 10's right ankle. Review of August 2024 MAR showed orders for a pain medication patch to be applied to Resident 10 two times a day and gave an area for staff to document the patch was put on at 8:00 AM and removed each night at 8:00 PM. This MAR showed staff documented the patch was applied on 08/14/2024 and removed on 08/14/2024 but was still observed on Resident 10 two days later. In an interview and observation on 08/16/2024 at 9:01 AM, Staff Z (Licensed Practical Nurse) confirmed the pain medication patch was from two days prior, removed the patch, and stated, we should not have missed removing the patch. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were provided with a program of individualized activities for 2 of 5 (Residents 95 & 150) residents reviewed for activities. These failures left residents at risk for boredom and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received care and treatment in accordance with professional standards of practice to attain or maintain their highest practicable level of well-being for 2 of 5 residents (Resident 60 & 85) reviewed. The facility failed to ensure Resident 60 was provided pain management, services for loose stools, or follow the Care Plan (CP) for 1 of 1 residents for edema (swelling caused by too much fluid trapped in the body tissue). These failures placed the residents at increased risk of worsening conditions, discomfort, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 2 of 4 residents (Residents 21 & 71) reviewed for bowel and bladder incontinence, received the care and services necessary to maintain and avoid loss of bowel and bladder functions. This failure placed the residents at risk for continued decline in bowel and bladder function, skin issues, and feelings of frustration and embarrassment.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were stored, labeled, and dated when opened and/or discarded when expired for 4 of 4 medication carts (100 Hall Cart 1, 200 Hall Cart 1, 200 Hall Cart 2, & 300 Hall Cart 1) and 2 of 2 medication rooms (Unit 200 East & Unit 200 West) observed. The failure to ensure unneeded medications and medical supplies were returned to the pharmacy or discarded when expired, medication refrigerators were monitored for appropriate temperatures, and medications were labeled for individual use placed residents at risk for ineffective treatment, expired medications, and contaminated medications

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect a resident's right to be free from sexual abuse for 1 of 3 residents (Resident 1) reviewed for sexual assault. This failed practice resulted in psychological harm, applying the reasonable person approach, for Resident 1 who experienced an attempted sexual act by another resident (Resident 2) and resulted in Resident 1 being transferred to a hospital emergency room (ER) for evaluation. This failed practice placed all residents at risk for the potential of sexual abuse, psychological harm, and diminished quality of life.

Inspectors wroteBased on observation, interviews, and record review the facility failed to provide cares and services consistent with professional standards of practice to promote the healing of existing pressure ulcers. Failure to provide the dietary supplement, Impact Advanced Recovery Oral Liquid, that 1 (Resident 1) of 8 residents reviewed for dietary supplements as ordered, left Resident 1 at risk for a decline in wound healing and weight loss.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain clean, sanitary surfaces and equipment in the kitchen and care floor utility rooms in accordance with standards for food service safety. The failure to 1) maintain a clean/sanitized kitchen, 2) maintain clean/sanitized ice machines, 3) maintain clean/sanitized microwaves, and 4) monitor/maintain resident refrigerator temperatures, placed residents at risk for cross-contamination, food-borne illnesses, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure conveyance (the act of legally transferring property from one entity to another) of a resident's trust funds, including a final accounting of those funds within 30 days of discharge for 2 of 2 discharged residents (Residents 602 & 603) reviewed for trust accounts. This failure prevented the residents from having access to their funds after leaving the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a safe, clean, and comfortable environment was provided. Facility failure to: maintain a clean and homelike environment on 3 of 4 units (the 2 East Unit & the 100 Unit); ensure handrails were secure for 2 of 4 units (the 100 Unit & the 300 Unit); ensure residents were able to secure their property for 1 of 29 sample residents (Resident 113), left residents at risk for a less then homelike environment, and missing property.

Inspectors wroteBased on observations, interview, and record review the facility failed to ensure 9 (Residents 13, 91, 10, 68, 137, 58, 42, 76 & 98) of 29 residents' Minimum Data Sets (MDS- an assessment tool) were completed accurately to reflect the residents' condition. This failure placed residents at risk for unidentified and/or unmet needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure: Care Plans (CPs) were implemented and revised as needed for 10 of 32 sample residents (Residents 10, 136, 137, 48, 84, 95, 58, 113, 74, & 132 ) and care planning conferences were conducted as required for 1 of 8 sample residents (Resident 23). These failures placed residents at risk for unmet care needs and negative health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to rotate injection sites for 1 (Resident 76) of 32 sampled residents, monitor for adverse side effects for 1 (Resident 98) of 32 sampled residents, follow Physician Orders (POs) for 2 (Residents 68 & 41) of 32 sampled Residents, clarifying POs for 3 (Residents 68, 48 & 42) of 32 sampled residents, signing for tasks not completed for 1 (Resident 68) of 32 sampled residents, and providing treatment without a PO for 1 (Resident 58) of 32 sampled residents. These failures placed residents at risk for unmet care needs, adverse side effects of medications going unnoticed by nursing staff, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who were dependent on staff to meet their Activities of Daily Living (ADLs) needs, were consistently provided necessary assistance for 7 (Residents 68, 84, 41, 42, 76, 11 & 132) of 12 sample residents reviewed. Failure to provide assistance to residents who were dependent on staff for bathing, oral care, nail care, assistance to get out of bed, and dressing placed residents at risk for unmet needs, poor hygiene, embarrassment, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure activity programs met the needs of each resident for 5 of 8 residents (Residents 23, 48, 74, 132 & 61) reviewed for activities. Failure to provide residents with meaningful activities left residents at risk for boredom, frustration, and a diminished quality of life.

Inspectors wroteBased on observation, interview, record review the facility failed to ensure 4 of 5 (Residents 13, 48, 42, & 113) residents reviewed for positioning, Range of Motion (ROM), and mobility, and 1 supplemental resident (Resident 84) received the care and services they were assessed to require. These failures placed residents at risk for decline in ROM, increased dependence on staff, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the facility was free of accident hazards for 4 of 9 residents (Residents 91, 95, 113 & 66) reviewed for accidents and 3 supplemental residents (553, 74 & 61). The failure to ensure mattresses were installed correctly (Residents 91, 113 & 66), wheelchair brakes were not used when not required by the resident (Residents 553, 95 & 61), and resident bedsides were free of hazards (Resident 74) left residents at risk for accidents, injuries, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper consistency and nutritional value was maintained to meet the nutritional needs for 21 residents prescribed a ground (crushed/ minced) and/or pureed (pudding-like) textured diet. The failure to follow the written recipe did not ensure the proper consistency or flavor of food served and placed the residents at risk for a diminished dining experience, and inadequate nutritional intake potentially leading to malnutrition and weight loss. Additionally, the facility failed to provide food that was palatable, attractive, and an appetizing temperature for 2 of 10 resident (Residents 125 & 66) reviewed for food and nutrition services. This failure placed residents at risk for a diminished dining experience, less than adequate nutritional intake, and potential weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that accommodated residents' food preferences and/or intolerances, provide options of similar nutrient value or provide opportunity to residents to request a different meal choice for 5 of 16 sampled residents (Residents 68, 137, 48, 11 & 23) and 1 supplemental resident (Resident 67) reviewed for food choices. The failure to 1) offer residents choices of foods served to them at meals, 2) provide food that followed the residents' personal likes/dislikes, 3) offer substitutions when residents were served foods they did not like and/or 4) offer replacements or supplements when meals were not eaten, placed residents at risk for malnutrition, weight loss and diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to consistently implement hand hygiene during care for 4 of 4 units (2 East, 2 West, and 3rd Floor), ensure staff used required Personal Protective Equipment (PPE - gowns, gloves, or masks) appropriately while providing care for a resident under isolation precautions for 1 of 1 resident(Resident 55) requiring isolation and ensure shared resident equipment was clean on 1 of 4 units (2 West). These failures placed the residents at risk for exposure to infectious diseases.

Inspectors wroteBased on observation, interview, and record review the facility failed to allow 4 (Residents 68, 48, 66, & 125) of 8 residents reviewed for choices, the right to make choices regarding important daily routines and health care, including accommodating preferences for the frequency and/or type of bathing, ability to access the community at leisure, and have access to water pitchers. The facility's failure to accommodate resident choice placed these residents at risk for a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who were hospitalized emergently were offered a bed hold (the opportunity to pay for the bed the resident currently occupied while out of the facility in order to ensure their bed/room was available when ready to return) for 2 of 7 residents (Resident 121 & 58) reviewed for hospitalization. Failure to offer bed holds placed residents at risk for unwanted, avoidable room changes upon readmission, and frustration.

Inspectors wroteBased on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) assessments accurately reflected residents' mental health conditions for 2 of 5 (Resident 137 & 58) residents reviewed for PASRR. This failure placed residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop person-centered comprehensive Care Plans (CPs) for 4 (Residents 68, 58, 76, & 98) of 32 residents whose CPs were reviewed. Facility failure to develop individualized, comprehensive CPs left residents at risk for unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure communication needs were met for 3 of 11 residents (Residents 91, 13 & 74) reviewed for alternative communication. Failure to ensure care planned communication interventions were implemented left residents at risk for unmet needs, frustration, social isolation, and a diminished sense of well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to: ensure newly identified skin issues, were assessed, and treated as required for 3 of 10 residents reviewed for skin conditions (Resident 13, 58, & 132); provide treatment residents were assessed to require for 2 of 29 sample residents (Residents 91 & 121); reposition the resident according to the Care Plan (CP) for 1 of 10 residents (Resident 95). These failures placed residents at risk for avoidable or worsening skin issues, and other negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure a licensed pharmacist's monthly Medication Regimen Reviews (MRRs) were added to resident records and recommendations were reviewed and incorporated for 3 of 5 (Resident 58, 76, & 98) residents reviewed for unnecessary medications. This failure placed residents at risk for delays in necessary medication changes and at risk of receiving medications without required pharmacist oversight. <Facility Policy> According to a January 2023 MRR and Reporting facility policy, the MRR consisted of a review of residents' medical records in order to prevent, identify, report, and resolve medication related problems, medication errors, or other irregularities. This policy indicated the facility's consultant pharmacist would review the medication regimen of each resident at least monthly. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents remained free of unnecessary psychotropic medications for 2 (Residents 48 & 58) of 5 sample residents whose medications were reviewed for unnecessary psychotropic medications. Failure to identify the adequate indications for use/extended use, identify triggers or specific behaviors, document behaviors, attempt Gradual Dose Reductions (GDR) or implement non-pharmaceutical interventions before administering medication, and failure to obtain informed consent prior to administration of Anti-Psychotic (AP) medications placed residents at risk of receiving unnecessary psychotropic medications, experiencing medication-related adverse side effects (ASE), and diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure: (1) medications were labeled with pharmacy labels to include the resident's name, cautionary instructions, and expiration dates when applicable, (2) expired medications were disposed of timely for 2 of 4 (2 [NAME] Medication Cart A and B) medication carts and 1 of 2 (2 [NAME] Medication Room) medication rooms reviewed for medication labelling and storage, and (3) medications were secured for 1 of 1 (Resident 68) residents observed with medications at bedside. These failures placed residents at risk for medication errors, receiving compromised medications with decreased or no potency, and inadvertent self-administration of medications by residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure prompt dental services were provided for 1 of 9 (Resident 113) residents reviewed for dental care. This failure placed Resident 113 and all other residents at risk for unmet dental needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to establish an infection prevention and control program that included developing an antibiotic stewardship program to promote appropriate use of Antibiotics (ABO's) and reduce the risk of unnecessary ABO use for 2 of 3 (Residents 452 & 58) residents reviewed for unnecessary ABO's. This failure placed residents at risk for potential adverse outcomes, associated with the inappropriate / unnecessary use of ABO's.

Inspectors wroteBased on interview and record review, the facility failed to ensure one (Resident 48) of five residents reviewed for unnecessary medications reviewed for vaccinations, received information on the current recommendations from the Center for Disease and Control and Prevention (CDC) related to Influenza and Pneumococcal vaccinations, and failed to ensure residents were offered the recommended vaccinations. This failure placed residents at risk for contracting Influenza and pneumonia, with its associated complications of infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to: (1) assess the compatibility of the mattress used and/or purchased separately from the bed frame for unsafe gaps, and (2) conduct routine inspections of all bed frames and mattresses as part of a regular maintenance program for 2 of 2 (Resident 113 & 66) resident beds reviewed for accident hazards. These failures placed residents at risk for injury, entrapment, or death.