Mount Washington Care Center

Review of the baseline care plan for Resident #71 dated 07/26/25 revealed resident was severely cognitively impaired, was dependent for all care, had a feeding tube for nutrition, and was a full code.

Review of a progress note for Resident #71 dated 07/26/25 revealed the note did not include documentation of physician's orders for tracheostomy care or oxygen administration.

Review of the admitting physician's orders for Resident #71 dated 07/26/25 revealed they did not include orders for tracheostomy care or oxygen administration.

Review of the Treatment Administration Record (TAR) for Resident #71 dated July 2025 revealed it did not include orders for oxygen administration or tracheostomy care.

Interview on 08/12/25 at 11:33 A.M. with the Director of Nursing (DON) confirmed there were no orders for tracheostomy care or oxygen administration for Resident #71 upon admission to the facility on [DATE].

The DON further confirmed Resident #71 was sent to the hospital on [DATE] and was admitted with respiratory distress.

The DON confirmed the facility staff relied on nursing judgment for the administration of oxygen and tracheostomy care for Resident #71.Interview on 08/12/25 at 1:44 P.M. with Licensed Practical Nurse (LPN) #109 confirmed Resident #71 was admitted to the facility on [DATE] from a subacute care hospital with a tracheostomy in place.

The discharge orders from the hospital did not include orders for tracheostomy care or oxygen administration. LPN #109 confirmed when Resident #71 arrived at the facility the resident was receiving oxygen and he continued to administer oxygen at four liters per minute (LPM), but the nurse did not receive or implement orders for tracheostomy care or oxygen administration. LPN #109 confirmed when he came to work on 07/27/25, Resident #71 was experiencing respiratory distress and had an oxygen saturation level of 68 percent (%). LPN #109 called the physician who told the nurse to increase the resident's oxygen flow rate and call 911. LPN #109 confirmed he increased Resident #71's oxygen from four LPM to seven LPM, and the resident's oxygen saturation rate was 76% when the emergency medical technicians arrived to take the resident to the hospital. LPN #109 confirmed he relied on nursing judgment to determine the LPM of oxygen for Resident #71.

Review of the facility policy titled Tracheostomy Care dated 2024 revealed tracheostomy care would be provided according to the physician's orders and in accordance with professional standards of practice with a general consideration to provide tracheostomy care at least twice daily.

This deficiency represents noncompliance investigated under Complaint Number 2584605.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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