Washington Center

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 10) with a gastrostomy tube (GT, a tube inserted through the wall of the abdomen directly into the stomach) had documentation of provision of ordered nursing care related to the GT. This failure resulted in impaired communication across shifts and had the potential to result in inaccurate assessments of needed care, and unnecessary duplication of care.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on interview and record review for two of five sampled residents (Resident 30, Resident 39), the facility failed to notify the Long Term Care (LTC) Ombudsman (an advocate for nursing home Residents) of resident transfers to acute care hospital. This deficient practice had a potential for Residents to not receive advocate support. 1. Review of Resident 30's clinical record showed a hospital admission on [DATE], and an emergency room visit on 1/26/19. The record did not reflect ombudsman notification of the transfers to the hospital. 2. A review of Resident 39's clinical record showed an emergency room visit on 12/10/18. The record did not reflect any notification to the Ombudsman for the emergency room visit. [...]

Inspectors wroteBased on interview and record review, the facility failed to document proceedings of the quality assessment and assurance committee during scheduled quarterly meetings. This failure had the potential to result in facility inability to monitor the ongoing, comprehensive evaluation of provision of facility care and services.

Inspectors wroteBased on the interview and record review facility failed to conduct quarterly meeting on a regular basis and required members were not in attendance. this deficient practice failed to, monitor departmental performance data routinely in order to identify deviations in performance .

Inspectors wroteBased on interview and record review, the facility failed to ensure the quality assessment and assurance committee had regulatory required members in attendance at the November 2018 quarterly meeting. This failure resulted in facility inability to routinely review and evaluate departmental performance data, and initiate necessary corrective actions.