Mount Washington Care Center

In the surveyor’s words

From the most serious findings on record at Mount Washington Care Center, in the surveyor’s own words.

• Actual harm, isolatedF697Mar 4, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Feb 4, 2022

  Based 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. Findings include: Observation on 01/27/22 at 9:24 A.M., revealed medicine storage room refrigerator on first floor had no monthly temperature log. Two thermometers were in the refrigerator with prescribed medications. The temperature in the refrigerator was appropriate at this time, but no monthly temperature log was present. […]

• No harm, potential for more than minimal, widespreadF880Oct 14, 2021

  Based on observation, staff interview, and review of facility policy and Centers for Disease Control and Centers for Medicare and Medicaid guidance, the facility failed to ensure staff wore personal protective equipment (PPE) appropriately. This had the potential to affect all residents in the facility. The facility census was 82. Findings include: 1. An observation was made of Licensed Practical Nurse (LPN) #50, on 10/04/21 at approximately 6:50 A.M. He was observed walking from the 100 hall into the COVID unit, only wearing an N95 mask. He was later observed walking off the unit continuing to only wear an N95 mask, no face shield/goggles and no gown. Interview with STNA #2 on 10/07/21 at 4:12 P.M. […]

• No harm, potential for more than minimal, widespreadF880Sep 7, 2021

  Based on observations, staff interviews, record reviews, review of the Center for Disease Control, and policy review, the facility failed to follow infection control practices to prevent the spread of Coronavirus Disease (COVID-19). This affected two (#14 and #30) of five reviewed for infection control and had the potential to affect all residents residing in the facility. The census was 80. Findings include: 1. Review of the medical record for Resident #14 revealed a re-admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment, dated 08/25/21, revealed this resident had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 12. […]

• No harm, potential for more than minimal, patternF657Mar 4, 2025

  Based 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. Findings include: 1) Review of the medical record revealed Resident #02 was admitted to the facility on [DATE]. Diagnoses included osteoarthritis of right knee, diabetes mellitus, Stage IV pressure ulcer (sacrum). […]