Inspection Reports for
Washington Care Center

The complaint investigation involved Resident 1 who fell from a mechanical lift due to staff not following the care plan requiring two caregivers. The fall caused traumatic brain injury and fractures. Multiple staff interviews confirmed failure to follow the Kardex and care plan. The complaint was substantiated.

The facility failed to ensure adequate supervision and assistance for one resident, leading to a fall from a mechanical lift and resulting in traumatic brain injury and fractures. Staff did not follow the care plan requiring two caregivers for mechanical lifts, placing other residents at risk.

The complaint investigation involved Resident 1 who fell due to inadequate supervision by staff. The fall caused actual harm with multiple fractures. The investigation confirmed staff failed to follow the care plan and some staff had not completed required training. The allegation was substantiated.

The facility failed to provide the assessed level of supervision for one resident, resulting in a fall that caused multiple fractures and increased pain medication. The investigation found staff did not follow the care plan, and some staff had not completed required training, placing other residents at risk.

The facility failed to maintain adequate infection control practices by not providing sufficient Personal Protective Equipment (PPE) for staff and having malfunctioning hand sanitizer dispensers in many resident rooms. These deficiencies placed residents at risk for communicable diseases and medical complications.

The facility was found deficient in multiple areas including failure to obtain informed consent for psychotropic medications, maintain a homelike environment, provide timely discharge notifications, complete PASRR Level II evaluations, update care plans, provide adequate assistance with activities of daily living, ensure proper medication administration and storage, maintain infection control practices, and ensure resident safety related to smoking and environmental hazards. Several residents were found at risk due to these deficiencies, but the overall harm level was minimal.

The complaint involved an incident on 05/22/2024 where Resident 2 was found on top of Resident 1 with pants down. Resident 1 was taken to the hospital for evaluation and STI testing. Resident 1 and Resident 2 gave conflicting statements about consent. Staff interviews revealed lack of prior awareness and monitoring of Resident 2's sexual behaviors. The allegation was substantiated with findings of actual harm and risk to residents.

The facility failed to protect a resident from sexual abuse, resulting in actual psychological harm and hospital evaluation. The investigation found conflicting resident statements and no physical evidence of assault, but confirmed the incident placed residents at risk and revealed inadequate monitoring of one resident's sexual behaviors.

The complaint investigation focused on Resident 1's failure to receive the ordered dietary supplement. Multiple staff interviews and record reviews confirmed the supplement was not available and not given, although nurses signed that it was administered. The complaint was substantiated based on these findings.

The facility failed to provide the ordered dietary supplement to Resident 1 as prescribed, despite nurses documenting administration when the supplement was not available. Multiple staff interviews confirmed the supplement was not given, and alternative supplements were provided instead. This failure posed a risk for decline in wound healing and weight loss.

No health deficiencies were found during this survey. The report indicates no citations or violations.

The facility was found to have multiple deficiencies including failure to accommodate resident choice, inadequate conveyance of resident funds, unsafe and unclean environment, inaccurate resident assessments, incomplete and outdated care plans, medication management issues, inadequate infection control practices, and failure to provide appropriate activities and nutrition. Some residents were not provided care as scheduled or according to their preferences. The facility also failed to maintain safe bed systems and ensure proper use of psychotropic medications. Several observations and interviews confirmed these deficiencies.

The facility failed to supervise a resident at risk for elopement who left the building unsupervised and sustained injuries requiring hospital evaluation. Additionally, the facility failed to maintain hot water heaters properly, causing multiple residents to be unable to shower with hot water. Several staff interviews and observations confirmed these deficiencies.

The complaint investigation focused on pressure ulcer care for Residents 1 and 2. Resident 1 developed multiple untreated pressure ulcers that worsened and required hospitalization. Resident 2 experienced worsening of a sacral pressure ulcer and developed new bilateral heel ulcers. The investigation found missed weekly skin assessments, failure to update care plans, and inadequate pain assessments. The allegations were substantiated as actual harm was documented.

The facility failed to provide appropriate pressure ulcer care and prevention, resulting in actual harm to two residents. Weekly skin assessments were missed, care plans were not updated timely, and multiple pressure ulcers were not identified or treated properly, leading to deterioration and hospitalization for Resident 1 and worsening ulcers for Resident 2.

The facility was found deficient in multiple areas including failure to assess and care plan for medication self-administration, failure to ensure residents' rights to formulate advance directives, failure to provide required Skilled Nursing Facility Advanced Beneficiary Notices, failure to maintain a homelike environment, failure to prevent and investigate abuse allegations properly, failure to develop timely baseline and comprehensive care plans, failure to provide adequate bathing and restorative nursing services, failure to ensure proper catheter care, failure to implement dietary orders, failure to provide timely dental services, failure to ensure sufficient nursing staff to meet resident needs, and failure to monitor psychotropic medication use appropriately. Some deficiencies were corrected during the survey period.