Washington County Nursing Home

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Provide care by qualified persons according to each resident's written plan of care.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).The campus comprises four single-story Type V (111) buildings, with each building accommodating 10 beds. The facility designated as building A1 is fully protected by automatic fire suppression systems that comply with National Fire Protection Association (NFPA) 13 standards. The attic space, mechanical area, and screen porch are safeguarded by a dry-piped automatic sprinkler system and are classified as fully sprinklered. The emergency power .. INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).The campus comprises four single-story Type V (111) buildings, with each building accommodating 10 beds. The facility designated as building B1 is fully protected by automatic fire suppression systems that comply with National Fire Protection Association (NFPA) 13 standards. The attic space, mechanical area, and screen porch are safeguarded by a dry-piped automatic sprinkler system and are classified as fully sprinklered. The emergency power .. INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).The campus comprises four single-story Type V (111) buildings, with each building accommodating 10 beds. The facility designated as building C1 is fully protected by automatic fire suppression systems that comply with National Fire Protection Association (NFPA) 13 standards. The attic space, mechanical area, and screen porch are safeguarded by a dry-piped automatic sprinkler system and are classified as fully sprinklered. The emergency power .. INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).The campus comprises four single-story Type V (111) buildings, with each building accommodating 10 beds. The facility designated as building D1 is fully protected by automatic fire suppression systems that comply with National Fire Protection Association (NFPA) 13 standards. The attic space, mechanical area, and screen porch are safeguarded by a dry-piped automatic sprinkler system and are classified as fully sprinklered. The emergency power .. STANDARD is not met, as evidenced by: Based on record review and staff interviews during the survey, it was determined that the facility failed to maintain emergency power systems in accordance with section 19.2.9.1 of the Life Safety Code and the referenced 2010 NFPA 110, Section 8.3.8 Maintenance and Operational Testing. This deficient practice has the potential to affect all residents, staff, and visitors in the event of power loss. The annual diesel fuel quality test, conducted using applicable ASTM Standards, failed due to samples containing levels of gasoline.NFPA 110, Section 8.3.8 a fuel quality test shall be performed at least annually using approved ASTM standards.The generator d.. STANDARD not met as evidenced by: Based on observation, it was determined that the facility failed to maintain the automatic sprinkler system per National Fire Protection Association (NFPA) Standard 13 and Standard 25. This deficient practice could affect all residents, staff, and visitors should the automatic sprinkler system fail to operate promptly and effectively due to non-code-compliant maintenance. Two gauges in the Fire Sprinkler Raiser room were manufactured in 2018. They shall be calibrated or replaced every five years.NFPA 101 2012 Edition Life Safety Code Standards require automatic sprinkler systems to be continuously maintained in reliable operating condit..

A recertification survey was conducted from 9/22/24 to 9/25/24. Four deficiencies were cited. An Emergency Preparedness survey was conducted from 9/22/24 to 9/25/24. No deficiencies were cited. Based on interviews, observations and record review, the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced their dignity and respect for one (#35) of three residents reviewed for dignity out of 19 sample residents.Specifically, the facility failed to ensure Resident #35' s fall intervention sensor alarm was discussed with the resident on how it made her feel. Findings include:I. Facility policy and procedureThe Elder rights policy, revised 7/8/24, was provided by the nursing home administrator (NHA) on 9/25/24/at 2:53 p.m. It read in pertinent part,"All elders will be treated equally regardless of age, race, ethnicity, religion, culture, languag.. Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases.Specifically, the facility failed to ensure nursing staff followed proper infection control procedures for a resident on enhanced barrier precautions (EBP).Findings include:I. Professional referenceThe Centers for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) (4/2/24), was retrieved on 9/26/24 from .. Based on record review and interviews, the facility failed to ensure drug regimens were free from unnecessary medications for one (#38) of five residents reviewed for unnecessary medications out of 19 sample residents. Specifically, the facility failed to ensure Resident #38 was adequately monitored and side effects were documented for the use of an anticoagulant medication.Findings include:I. Facility policy and procedureThe Anticoagulant policy, revised 8/24/24, was provided by the nursing home administrator (NHA) on 9/25/24 at 2:53 p.m. It read in pertinent part, "As part of the initial assessment, the physician and staff will identify individuals who are currently anticoagula.. Based on record review and staff interviews, the facility failed to develop and implement a comprehensive care plan for three (#38, #24 and #3) of five residents reviewed for care plans out of 19 total sample residents.Specifically, the facility failed to: -Ensure Resident #38 had a care plan for the use of an anticoagulant medication;-Ensure Resident #24 had a care plan for the use of supplemental oxygen; and,-Ensure Resident #3 had a care plan for the use of a diuretic medication. Findings include:I. Facility policy and procedureThe Care Plan policy, revised 8/12/24, was provided by the nursing home administrator (NHA) on 9/25/24 at 2:53 p.m. It read in pertinent part, "A comprehensi..