Washington Ctr for Aging Svcs

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations and staff interviews, the facility staff failed to: 1) post the results of its most recent survey in a place readily accessible to residents, family members, and resident representatives and 2) have reports from the three preceding years, including certification surveys, complaint investigations, and any plan of correction in effect with respect to the facility available upon request for any individual to review.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record view, staff interview and family interview, the facility failed to implement its discharge planning process to ensure a safe discharge for one (1) of three (3) sampled residents that were discharged home. (Resident #221)

Inspectors wroteBased on observations, record reviews and staff interviews for six (6) residents and one (1) of three (3) of the six (6) residents with an active diagnosis of Dysphagia, it was determined that the facility's staff failed to ensure that Resident #1 was provided with adequate monitoring during meals, had a physician order to provide close supervision while eating, ensured speech documentation contained accurate information related to diet and liquid consistency, completed speech recommendations following a Modified Barium Swallow Study that showed laryngeal aspiration and failed to implement special dietary instructions for the resident whose diagnoses include oropharyngeal dysphagia. Subsequently, these failures resulted in the resident choking on food while eating alone in his room. [...]

Inspectors wroteBased on record review and staff interviews, for one (1) of 1 sampled residents who had an outside speech-language pathologist consultation, the facility failed to have documented evidence that they discussed with the resident's physician: (1) they were not able to schedule a Modified Barium Swallow Study (diagnostic test) in 8 weeks, as recommended by outside speech therapist on 03/06/25 and approved the facility's nurse practitioner on 03/07/25; and (2) the resident not provided swallowing exercises, chin tucks, and effort swallow techniques as recommended by an outside speech-language pathologist on 03/06/25 and approved the facility's nurse practitioner on 03/07/25. (Resident #1)

Inspectors wroteBased on an observation, record reviews, and staff interviews, the facility failed to ensure Comprehensive Assessments contained accurate information for two (2) of six (6) sampled residents. (Residents #1 and #5)

Inspectors wroteBased on observation, record review, and staff interview, for one (1) of six (6) sampled residents, the facility failed to develop a care plan to address the resident's need for staff assistance with eating. (Resident #6)Resident #5 was admitted on [DATE] with multiple diagnoses including History of Dysphagia, Adult Failure to Thrive, and Dementia. An observation on 07/07/25 at approximately 12:50 PM showed the resident sitting in the day room sitting in a Geri-chair watching tv. The resident was alert and oriented to name. At the time of the observation, Employee #16 (CNA) holding a cup of water to the resident's mouth for the resident to drink. A review of the care plan lacked documented evidence of goals and interventions to address the resident's need for total assistance from staff with eating and drinking. [...]

Inspectors wroteBased on record reviews and interviews, facility staff failed to have documented evidence that the IDT team reviewed residents care plans or held care plan conferences with the resident and/or the resident's family after each Minimum Data Set (MDS) assessment for two (2) of six (6) sampled residents. (Residents #1 and #5)

Inspectors wroteBased on record reviews and staff interviews, for one (1) of six (6) sampled residents, the facility failed to ensure that the resident's speech-language pathology treatment notes and care plan contained accurate information. (Resident #1).

Inspectors wroteBased on observations, record reviews, staff and resident interviews for one (1) of 59 sampled residents, facility staff failed to ensure that adequate supervision was provided to Resident #21, as evidenced by documentation in the residents medical records of staff observing Resident #21 smoking and possessing smoking paraphernalia while using supplemental oxygen continuously and the surveyor observing the facility staff failing to provide one to one monitoring of Resident #21 as instructed by physician orders on multiple occasions during the survey. Resident #21. Due to these failures, an immediate jeopardy situation was identified on July 9, 2024, at 4:36 PM. The facility submitted a plan of action to the survey team that was onsite at 1:12 AM on July 10, 2024, and the plan was accepted. [...]

Inspectors wroteBased on record review and interview, the facility staff failed to have documented evidence that the residents or their representative were made aware that their accounts were above the maximum limit of $4000 for 16 of 16 sampled residents.

Inspectors wroteBased on observation, record review and staff interviews for six (6) of 59 sampled residents, facility staff failed to ensure each resident received an accurate assessment reflective of the resident's status at the time of the assessment for a resident: with a history of falls; who requires repositioning assistance; with weight loss; on prescribed psychotropic medications; with a surgical wound; and who is prescribed use of supplemental oxygen. Residents' #496, #501, #95, #45, #133, and #21.

Inspectors wroteBased on record review and resident and staff interviews for two (2) of 59 sampled residents, facility staff failed to develop a care plan that addressed a resident who was visually impaired and had glaucoma and failed to implement the approaches on a resident's care plan that addressed the resident's need for follow-up with audiology, resulting in the resident obtaining an appointment nine months after staff documented hearing as a concern. Residents #112 and #162.

Inspectors wroteBased on observation, record review and staff interviews for one (1) of 59 sampled residents, facility staff failed to treat a resident with respect, dignity, and care, as evidenced by administering advanced life support measures to a resident who was not a Full Code. Resident #498.

Inspectors wroteBased on observation, record review and staff interviews for one (1) of 59 sampled residents, facility staff failed to ensure that a resident was free from physical restraint not required to treat the resident's medical symptoms, as evidenced by a siderail up at the foot of the resident's bed. Resident #105.

Inspectors wroteBased on record reviews and staff interviews for one (1) of 59 sampled residents, the facility staff failed to implement its policies and procedures for reporting and conducting investigations into potential allegations of neglect and or abuse. Resident #128.

Inspectors wroteBased on record reviews and staff interviews for one (1) of 59 sampled residents, the facility staff failed to show documented evidence that the facility reported the results of a follow up investigation to the State Agency within 5 working days of incidents in which Resident #128 was found unresponsive on 11/14/23, 3/5/24 and found with an injury of unknown origin and change in behavior on 4/10/24. Resident #128.

Inspectors wroteBased on record reviews and staff interviews for three (3) of 59 sampled residents, facility staff failed to show documented evidence that thorough investigations were conducted for: 1) two incidents in which Resident #128 was found unresponsive on 11/14/23 and 3/5/24, and 2) one incident in which Resident #159 sustained an injury of unknown origin.

Inspectors wroteBased on record reviews and staff interviews for two (2) of 59 sampled residents the facility staff failed to provide documented evidence of providing notification to the resident or resident guardian of the reason for the residents transfer to the hospital emergency room. Residents' #32 and # 445.

Inspectors wroteBased on record review and staff interviews for two (2) of 59 sampled residents, the facility staff failed to provide documented evidence of forming a baseline care plan upon the residents readmissions to the facility. Residents #32 and #445.

Inspectors wroteBased on record review and staff interview, for one (1) of 59 sampled residents, the facility staff failed to update the comprehensive care plan with goals and approaches that address the resident's post-dialysis care for a right upper arm AVF [Arteriovenous fistula] access site and respiratory care /treatment. (Resident #249).

Inspectors wroteBased on observation, record review and staff interviews for one (1) of 59 sampled residents, facility staff failed to ensure that a resident who is unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Resident #105. Resident #105 was admitted to the facility on [DATE] with multiple diagnoses that included: Blindness Both Eyes, Psychotic Disorder with Delusions, Hallucinations, Morbid Obesity and Muscle Weakness. A review of Resident #105's medical record revealed: A Care Plan Problem dated 05/17/2023 documented, Category: ADLs (Activities of Daily Living) Functional Status/Rehabilitation Potential, Self care deficit and Evaluation Notes: 11/16/2023, Staff will continue to provide total ADL care. A Physician Note dated 05/10/2024 at 11:44 pm documented, debilitated, bedbound and dependent with all ADLs. [...]

Inspectors wroteBased on record review and resident and staff interviews for two (2) of 59 sampled residents, facility staff failed to provide care and services for a resident newly diagnosed with cancer, as evidenced by failing to ensure that the resident had scheduled follow-up oncology appointments and had transportation to the appointments.

Inspectors wroteBased on record review and resident and staff interviews for two (2) of 59 sampled residents, facility staff failed to ensure that residents received the proper treatment and assistive devices to maintain vision and hearing abilities as evidenced by failure to schedule an ophthalmology consult appointment for a resident with Diabetes and Glaucoma, and failure to schedule an initial audiology consult appointment for a resident with impaired hearing. Residents #112 and #162.

Inspectors wroteBased on observation record reviews and staff interviews for one (1) of 59 sampled residents, facility staff failed to ensure that the resident received respiratory care, consistent with professional standards of practice and the physicians orders as evidenced by the facility's staff's failure to follow the physicians order to place a date and initials on the residents oxygen tubing once each week and the staff failed to display an oxygen in use and no smoking sign in the residents room.

Inspectors wroteBased on observations and staff interview, facility staff failed to distribute foods under sanitary condition, as evidenced by two (2) of two (2) defective temperature gauges from one (1) of one (1) food warmer, that failed to register the upper and lower internal temperatures of the food warmer.

Inspectors wroteBased on record review and staff interview, facility failed to correct and monitor deficiencies identified on the previous survey that involved baseline care plans and implementing care plan interventions. The census on the first day of the survey was 194.

Inspectors wroteBased on observations on June 25, 2024, at approximately 2:30 PM, and staff interview, it was determined that facility staff failed to maintain essential equipment in good working condition, as evidenced by three (3) of seven (7) hopper sinks, that failed to operate as intended.

Inspectors wroteBased on observation, record review and staff interviews for one (1) of 59 sampled residents, facility staff failed to provide a safe, functional, sanitary, and comfortable environment for a resident who is totally dependent on staff, as evidenced by the resident's room filled with clutter. Resident #105.

Inspectors wroteBased on observation, record review and staff interview, facility staff failed to provide a facility-wide assessment that included the physical environment and space used for the resident's outdoor activities.

Inspectors wroteBased on record review and staff interview, the facility's staff failed to protect a vulnerable resident from Resident #90. This was evidenced by Resident #90 being observed by staff kissing Resident #16 who did not have the capacity to consent. As a result of these failures, an immediate jeopardy (IJ) was identified on August 31, 2023, at 2:33 PM. The facility provided a plan of action to address the immediate concerns on August 31, 2023, at 11:41 PM and it was accepted. On September 6, 2023, at 1:20 PM, while the survey team was onsite the plan was verified and immediacy was lifted. After removal of the immediacy, the deficient practice remained for the potential for more than minimal harm at a scope and severity of D.

Inspectors wroteBased on observations and interview, facility staff failed to provide housekeeping services necessary to maintain a safe, clean, comfortable environment as evidenced by expired nutritional food items such as seven (7) of nine (9) eight-ounce containers of Jevity, 1.5 calories nutritional drinks that expired on May 2022, two (2) of nine (9) eight-ounce containers of Jevity, 1.5 calories nutritional drinks that expired on May 2023, six (6) of six (6) eight-ounce Osmolite nutritional drinks that expired on August 1, 2023, 19 of 19 eight fluid ounce containers of Jevity, 1.5 calories nutritional drinks that expired on November 1, 2021, and six (6) of six (6) eight fluid ounce containers of Nestle boost nutritional drinks that expired on August 19, 2023, that were stored on three (3) of eight (8) resident care units. [...]

Inspectors wroteBased on record review and staff interview, for two (2) out of 42 sampled residents, facility staff failed to accurately code the Minimum Data Set (MDS) assessment for resident #125 for dialysis, and resident #37 for a fall.

Inspectors wroteBased on record review, resident interview, and staff interview, the facility's staff failed to develop a care plan how staff were to address Resident #90 sexual inappropriateness toward Resident #16 on 09/03/22 and failed to implement approaches to monitor and record Resident #124's complaint of pain as indicated on the comprehensive care plan.

Inspectors wroteBased on observation, record review and staff interviews, the facility's staff failed to identify and eliminate environmental hazards (nonfunctioning alarm on exit door) and maintain consistent supervision and surveillance of Resident #144, who subsequently gained access to elope through a broken patio door.

Inspectors wroteBased on observation, record review and staff interviews, facility staff failed to develop a narcotic count sheet that identified two (2) licensed nurses to reconcile the resident's narcotic medications.

Inspectors wroteBased on observations and interview, facility staff failed to store and distribute food under sanitary condition as evidenced by food items such as one (1) of one (1) bag of shredded carrots, approximately 50 of 50 containers of apple sauce and approximately 120 cold sandwiches of tuna, turkey and cheese, ham and cheese, and/or peanut butter that were observed undated in one (1) of one (1) walk-in refrigerator, one (1) of (1) bag of provolone cheese in reach-in refrigerator #2 that was not labeled, and two (2) of two (2) open packs of yellow cheese in the cook refrigerator that also was not labeled or dated.

Inspectors wroteBased on observation, record review and staff interviews for one (1) of 42 sampled residents, facility staff failed to show documented evidence that Resident #20's Humalog insulin was administered as ordered by the physician to treat finger stick blood glucose results greater than 250mg (milligram)/dl (deciliter).

Inspectors wroteBased on record reviews and staff interviews, the facility's staff failed to ensure that the comprehensive Quality Assurance and Performance Improvement (QAPI) plan was implemented to correct identified deficiencies related to implementing abuse policy, reporting allegation of abuse, or thoroughly investigating abuse. The resident census on the first day of the survey was 170.

Inspectors wroteBased on observation, record review and staff interview for five (5) of 56 sampled residents, facility staff failed to accurately code the Minimum Data Set for one (1) resident who had episodes of anxiety; one (1) resident having impairment on one side; one (1) resident for dialysis; one (1) resident for shortness of breath, and for one (1) resident for discharge assessment. Residents' #60, #100, #134, #179 and #181.

Inspectors wroteBased on observation, record review and staff interview, for two (2) of 56 sampled residents, facility staff failed to ensure that residents received treatment and care in accordance with professional standards of practice as evidence by: failure to follow the hospital discharge instructions to continue the administration of an antibiotic for two days to treat one (1) resident with a diagnosis of a urinary tract infection, and to apply the palm guard to one (1) resident's left hand in accordance with the physician's order. Residents' #29 and #100.

Inspectors wroteBased on record review and staff interview, facility staff failed to: complete the residents Medication Regiment Review (MRR) assessment in accordance with accepted professional standards of practice for three (3) residents, to ensure one (1) residents History and Physical was dated on completion and failed to document the correct dialysis access location for one (1) resident. Residents' #7, #60, #148, #162, and #177.

Inspectors wroteBased on observation and staff interview, facility staff failed to maintain the call bell system in good working condition as evidenced by call bells that failed to initiate an audible or visual alarm when tested in five (5) of 46 resident's rooms.

Inspectors wroteBased on observations and staff interview, facility staff failed to provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable environment as evidenced by a loose privacy curtain bracket in one (1) of 46 resident's rooms, stained ceiling tiles in one (1) of 46 resident's rooms, and two (2) of five (5) ceiling vents that lacked a cover in the hallway of unit 2 Orange.

Inspectors wroteBased on record review and staff interviews, facility staff failed to ensure all required documents were conveyed to the receiving health care provider for two (2) of 56 sampled residents that were transferred from the facility to the hospital. Residents' #148 and #161.

Inspectors wroteBased on record review and staff interview, the facility staff failed to provide residents and residents representatives with Notice of Discharge, Transfer or Relocation and the written Notices of a Statement of Appeal for two (2) of 56 sampled residents that were transferred to the hospital. Resident's #129 and #161.

Inspectors wroteBased on record review and staff interview, the facility staff failed to provide written information to the resident or resident representative that explained the duration of their bed-hold for one (1) of 56 sampled residents that were transferred to the hospital. Resident #148.

Inspectors wroteBased on record review and staff interview, for two (2) of 56 sampled residents, facility staff failed to update a resident's care plan to address one (1) resident with iron deficiency-anemia to include person-centered measurable objectives and time frames and for one (1) resident with a perm-a-cath access site for dialysis treatment. Residents' #99 and #134.

Inspectors wroteBased on observations and staff interview, the facility staff failed to provide an environment free from accident hazards as evidenced by surge protectors that were observed in use, on the floor of two (2) of 46 resident's rooms and an extension cord that was observed in one (1) of 46 resident's rooms.

Inspectors wroteBased on record review and staff interview, for three (3) of 56 sampled residents, facility staff failed to conduct a Medication Regimen Review (MRR) at least monthly. Residents' #60, #162 and #177.

Inspectors wroteBased on record review and staff interview, for two (2) of 56 sampled residents, facility staff failed to promptly notify the ordering physician of laboratory results that fall outside of a clinical reference range in accordance with facility policies and procedures for notification. Residents' #7 and #99.

Inspectors wroteBased on observation, record review and staff interview, on three (3) of three (3) observations, facility staff failed to maintain infection control and prevention practices in accordance with standards of practice to minimize the potential spread of infections.