Washington Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to provide adequate supervision for one of two sampled residents (Resident 1). Despite being a known elopement and fall risk, Resident 1 left the facility lobby unnoticed by staff. This failure in care caused Resident 1 to suffer a fall during an episode of elopement. A review of Resident 1's Face sheet indicated that the resident was admitted to the facility on [DATE] with diagnoses which included history of falling and muscle weakness. During a review of Resident 1's MDS (an assessment tool) Section C (assesses a nursing home resident's cognitive patterns, including attention, orientation, short and long term memory, recall, and the presence of delirium) dated 5/15/26, Section C indicated Resident 1's cognition was moderately impaired. The MDS Section GG (measures a resident's functional abilities and goals, focusing on self-care and mobility) titled Functional Abilities indicated that Resident 1 used a manual wheelchair and needed partial/moderate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and facility policy review, the facility failed to ensure the nursing staff locked two of four medication carts when it was not in their eyesight view. This failure had the potential for unauthorized users to access medications. Findings included: During a concurrent interview and observation of medication administration on 11/05/2024 at 7:02 AM and 7:09 AM, Registered Nurse (RN) 1 left medication cart labeled Lower 200 unlocked and out of her view in the hallway and entered a resident's room to administer medication. RN 1 stated the medication cart should be locked and that she forgot. The unlocked, unsecured medication cart contained several medications, not limited to Lasix to treat high blood pressure and fluid retention, Eliquis to prevent blood clot formation, and nitroglycerin to treat acute chest pain. During an interview on 11/05/2024 at 11:22 AM, RN 5 stated nurses must lock the medication cart and computer screen when they step away from the medication cart. During an interview on 11/05/2024 at 11:46 AM, Licensed Vocational Nurse (LVN)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and facility policy review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) for three (Residents 12, 28, and 78) of 21 sampled residents. This failure had the potential to result in inaccurate care plans and inadequate care provisions. Findings included: 1. An admission Record indicated the facility admitted Resident 78 on 06/25/2024. According to the admission Record, the resident had a medical history that included a diagnosis of encounter for other orthopedic aftercare. A quarterly MDS, with an Assessment Reference Data (ARD) of 09/30/2024, indicated Resident 78 was administered an anticoagulant medication in the last seven days. Resident 78's Order Summary Report for the timeframe 06/25/2024 to 11/30/2024, revealed no evidence to indicate the resident was ordered an anticoagulant medication. During an interview on 11/06/2024 at 9:37 AM, the MDS Coordinator stated she was responsible for section of the MDS that involved what kind of medication residents took during the look-back period. The MDS Coordinator stated it was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, facility policy review, the facility failed to ensure staff implemented enhanced barrier precautions (EBP) for one (Resident 2) of 21 sampled residents. This failure had the potential to result in the spread of infection. Findings included: An admission Record revealed the facility admitted Resident 2 on 02/27/2024. According to the admission Record, the resident had a medical history that included a diagnosis of encephalopathy, sepsis, enterococcus, methicillin resistant staphylococcus aureus infection and gastrostomy status. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/17/2024, revealed Resident 2 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident 2 had a feeding tube. Resident 2's care plan included a focus area, initiated 05/17/2024, that indicated the resident required enhanced barrier precautions (EBP) related to gastrostomy tube (G-tube) placement. Interventions directed staff to use gown and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to serve and store food under sanitary conditions by: 1. The tuna salad was held at an unsafe temperature in the refrigerator. 2. Dry food bin lids, utensils, and equipment were dusty. 3. A dented canned good was stored in a rack for use. These failures placed residents at risk of developing food-borne illnesses. Findings: 1. During the initial kitchen observation on 2/25/19 at 3:50 p.m., the refrigerator had a sealed container labeled tuna salad, start date 2/24/19. DM confirmed the current measured internal temperature of the tuna salad to be 48 degrees Fahrenheit (°F). DM stated refrigerated food should be stored at or below 41°F. (Tuna is a Time/Temperature Control for Safety Food, requiring control of time and temperature to limit the growth of harmful, disease producing organisms.) 2. The lids of five of five dry food storage bin lids were dusty. DM stated dietary aides, including herself, checked utensils and equipment for cleanliness and proper storage in clean areas. DM stated dry food bin lids are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to revise the comprehensive care plans for activities for two of three sampled residents (Resident 30 and Resident 39) after changes in physical conditions. These failures had the potential for Resident 30 and Resident 39 to receive inappropriate activities, or have unmet psychological and/or emotional needs from lack of appropriate activities. Findings: 1. A review of Resident 30's face sheet dated 1/24/19 indicated she originally admitted to the facility in 2015, and readmitted on [DATE]. The Significant Change in Status Minimum Data Set (MDS, an assessment tool used to guide care) dated 6/27/18, indicated her diagnoses included dementia (a brain disorder affecting the ability to remember, think clearly, communicate, and perform daily activities and that may cause changes in mood and personality), and generalized muscle weakness. The MDS reflected Resident 30 rarely/never understood others, or was understood; had severely impaired hearing;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate grooming services for one of one sampled resident (Resident 39) to prevent or treat dandruff (a skin condition usually confined to the scalp, and resulting in accumulation of dry, itchy, flaky scales). This deficient practice resulted in physical discomfort for Resident 39, and had the potential to result in emotional distress from poor grooming negatively impacting her physical appearance. Findings: A review of Resident 39's face sheet dated 7/19/18 indicated she was originally admitted to the facility in 2014, and readmitted on [DATE]. According to the Significant Change in Status Minimum Data Set (MDS, an assessment tool used to guide patient care) dated 1/11/19, had generalized muscle weakness. Review of Resident 39's care plan titled, .it is important that she has the opportunity to engage in daily routines that are meaningful ., revised 1/28/19, reflected as an intervention, It is important for me to keep clean.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide pressure ulcer treatment and services (pressure ulcer, a wound from prolonged pressure, also known as a bed sore) for one of five sampled residents (Resident 47). For Resident 47 the development of a pressure sore on 2/19/19, and the facility failure to provide treatment and services for eight days, resulted in increased size and depth of the ulcer, and had the potential to result in severe tissue damage at the site. Findings: A review of Resident 47's comprehensive admission Minimum Data Set (MDS, an assessment tool used to guide care) dated 1/18/19 showed Resident 47 was always incontinent of bladder and bowel, and required physical assistance from two people for turning and repositioning in bed. The MDS showed Resident 47 had clear speech, and was usually able to understand and be understood by others. The MDS indicated Resident 47 was at risk for pressure ulcers, but had no healed, or unhealed, pressure ulcers. A review of Resident 47's care plan, At Risk for Skin Breakdown, initiated on 11/5/14,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure one of 18 sampled residents (Resident 30) had complete, accurate, and readily accessible records. 1. For Resident 30, the facility failed to ensure care plans accurately represented patient care issues by initiating a care plan for anticoagulant medication (medication used to prevent abnormal clotting of the blood) not ordered or administered. This failure had the potential to result in unnecessary care adjustments such as patient education and dietary changes to prevent adverse effects associated with anticoagulant medications. 2. The facility failed to ensure accurate documentation of treatment when Resident 30's treatment record reflected nursing provided wound care to a resolved left upper thigh blister, and failed to accurately reflect treatment of a right thigh wound. This failure had the potential to result in impairment of nursing ability to monitor, evaluate, and plan interventions on an ongoing basis. Please refer to tags F 656 and F…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.