Washington Odd Fellows Home

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from sexual abuse by Resident 1 for 1 of 5 residents (Resident 2) reviewed for abuse. This failure placed the residents at risk for continued abuse, injury, and emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure professional standards of practice were followed when nursing staff failed to accurately document insulin (an injectable medication used to regulate blood sugar levels) administration for 1 of 3 residents (Resident 1) reviewed for medication administration. This failure placed the residents at risk for unstable blood sugars, duplicate administration of the medication, and adverse outcomes.

Inspectors wroteBased on observation and interview the facility failure to ensure food was prepared and served for (1 of 1 kitchen) in accordance with professional standards of safety. Facility kitchen staff did not wear facial hair restraints and beard restraints while serving residents food. This failure left residents at risk of food contamination and food-borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to review and validate the Preadmission Screening and Resident Reviews (PASARR, an assessment to ensure individuals with serious mental illness [SMI] or intellectual/developmental disabilities are not inappropriately placed in nursing homes for long term care) were correct on admission and had a required level two referral if residents had a positive level one PASARR for 4 of 7 residents (Residents 41, 1, 5, and 30) reviewed for PASARR. This failure placed the residents at risk for not receiving the care and services appropriate for their mental health needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision, revised care plan interventions for efficacy, and ensured care planned interventions were consistently followed to prevent avoidable repeated falls for 3 of 3 residents (Residents 51, 15, and 28) reviewed for falls. This failure placed the residents at risk for unsupervised self-transfers leading to falls, serious injury, and a decline in health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure visitation rights were protected for 1 of 2 residents (Resident 5) when their friend was restricted from talking to the resident without their knowledge. This failure placed the resident at risk of isolation, abandonment, and the ability to be independent regarding their own visitor choices.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents personal fund accounts were, A) deposited in an interest bearing account for 4 of 5 residents (Residents 25, 23, 8, and 28) reviewed for personal funds accounts, and B) made available to residents on the weekend for 2 of 5 residents (Residents 8 and 28) reviewed for personal funds. This failed practice caused residents not to receive or have access to monies owed to them.

Inspectors wroteBased on interview and record review, the facility failed to implement 4 of 8 components (identify, protect, report, and investigate) of their abuse/neglect policy/procedure after allegations of abuse were reported as a grievance (a formal complaint that highlights a violation of contract terms or policy) to the facility for 2 of 3 residents (Residents 8 and 41) reviewed for abuse/neglect. This failure placed the residents at risk for further abuse, fear, and unmet care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure residents dependent on staff received consistent showers for 2 of 5 residents (Residents 6 and 41) reviewed for activities of daily living (ADLs) care provided for dependent residents. This failed practice placed the residents at risk for unmet care needs, impaired skin integrity, and embarrassment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Trauma-Informed Care related to assessing trauma and identifying trigger-specific (a psychological stimulus that prompts recall of a previous traumatic event) interventions for residents with a history of trauma for 1 of 1 resident (Resident 41) reviewed for trauma informed care.

Inspectors wroteBased on interview and record review the facility failed to implement and ensure their system of records for controlled substances (categories of drugs, regulated and classified based on their potential for abuse, potential to cause physical or psychological dependence) disposition (the process of returning and/or destroying unused medications) and accurate reconciliation (a system of recordkeeping that ensures an accurate inventory of controlled substances received, administered or destroyed) was completed in sufficient detail to enable the accurate accounting with these types of medications for 1 of 2 medication carts reviewed and 1 of 1 narcotic (a type of medication for pain relief or sedation and is a category within controlled substances) destruction logbook reviewed for storage/disposition of controlled medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop/implement components of their infection prevention and control precautions regarding, A) Legionella (a bacteria that can cause a severe respiratory disease) testing protocols, identification of areas at risk and procedures for when control measures (actions or steps taken), adopted to reduce the potential growth/spread of pathogens (bacteria, virus or other microorganisms that can cause diseases) in water, were not met for 1 of 1 water management program (WMP) reviewed for infection control, and B) Nursing Staff hand hygiene and glove change for 1 of 3 residents (Resident 3) reviewed for infection control. The failure to implement the infection control components placed residents at an increased risk for exposure to cross contamination (harmful spread of diseases) and transmission of infectious diseases.

Inspectors wroteBased on observation and interview, the facility failed to provide a clean sanitary environment for 1 of 1 Kitchen floor area that had an uncleanable surface. This failed practice of an uncleanable surface could potentially placed staff and residents at risk of illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nursing staff posting was posted daily and/or reflected the actual nursing staff hours worked during 4 of 5 days (08/04/2025 through 08/07/2025) of the survey period. This failed practice prevented residents, family members, and visitors from knowing the facility's actual number of available nursing staff.

Inspectors wroteBased on interview and record review, the facility failed to periodically inform residents of their rights after residents were admitted to the facility for 7 of 10 residents (Residents 2, 5, 8, 10, 16, 28, and 31) and 1 of 1 Resident's Representative (RR, Resident 19) reviewed for resident rights. This failure placed residents at risk of not being informed of their rights and/or to make informed decisions regarding their rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the required contact information to resident advocacy resources (ombudsman, State Agency (SA), Aging and Long Term Care), or how to file a complaint with the SA for 7 of 11 residents (Residents 2, 5, 8, 10, 16, 28, and 31) and 1 of 1 Resident Representative (RR, Resident 19) reviewed for required notices and contact information. This failure placed the residents at risk of abuse, neglect, and not having resources available to them.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control interventions intended to prevent the spread of communicable disease during a COVID-19 (infectious disease by a new virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death) outbreak were consistently implemented for the use of: personal protective equipment (PPE) during COVID-19 testing for 3 of 3 staff (Staff G, J, and K); [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure treatment and care was provided in accordance with professional standards of practice and the comprehensive, person-centered care plan for 5 of 5 residents (Residents 54, 11, 38, 36, and 13) reviewed for quality of care, in the areas of constipation/urinary bladder assessment, fluid restrictions, and timely implementation of physician orders. Resident 54 experienced harm when they did not have a bowel movement for four days and did not have a timely urinary bladder assessment, that resulted in pain, constipation, a small bowel obstruction (a blockage in the intestines), and a urinary bladder infection that required hospitalization. These failed practices placed residents at risk for a delay in treatment and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary treatment and services to prevent the occurrence of an avoidable pressure ulcer (PU-injury to skin and underlying tissue resulting from prolonged pressure) and implement wound care and services timely to avoid worsening of a PU for 3 of 5 residents (Residents 48, 108, and 13) reviewed for PU's. Resident 48 experienced harm when the facility failed to follow physician orders to ensure healing of their avoidable Stage 4 PU (a full thickness tissue loss of tissue with exposed bone, tendon, or muscle) to their coccyx (tailbone) and obtain pain control measures during wound care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the assessed level of supervision required to prevent avoidable accidents for 1 of 1 resident (Resident 54) reviewed for falls with injuries. Additionally, the facility failed to identify active smokers, and the level of supervision required to smoke safely, for 3 of 3 residents (Resident 214, 216, and 212) reviewed for smoking. Resident 54 experienced harm when they fell while using their front wheel walker with a right sided platform attachment (a support that attaches to the walker to support the forearm and shoulder) when walking to the bathroom unsupervised that resulted in a laceration above the right eyebrow and fractured right ribs. The failure to identify potential hazards and implement adequate supervision placed the residents at risk for falls, injury, and an unsafe living environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received dignified care and services related to the lack of 1) timely assistance with toileting needs for 1 of 2 residents (Resident 10) reviewed for embarrassment after an incontinent episode; 2) serving meals at the same time at their dining table for 4 of 22 residents (Residents 10, 11, 33, and 36) reviewed for dining; and 3) providing dignity and respect during the admission process for 2 of 2 residents (Residents 217 and 208) reviewed for admissions. These failures placed the residents at risk for not attaining their highest practicable level of well-being.

Inspectors wroteBased on interview and record review, the facility failed to issue a Notice of Medicare Non-Coverage [(NOMNC) a notice that indicates when your care is set to end from a skilled nursing facility] as required for 1 of 3 residents (Resident 215) reviewed for beneficiary notification. Additionally, the facility failed to provide a Skilled Nursing Facility (SNF) Advance Beneficiary Notice [(ABN) a notification that provides an estimated cost of continuing services which may no longer be covered by Medicare; beneficiaries may choose to continue services but may be financially liable] for 3 of 3 residents (Residents 215, 50, and 52) reviewed for SNF ABN requirements. These failures placed the residents at risk for the inability to make informed financial and care decisions related to their continued stay.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review [(PASARR) - a federally required form that is used to help ensure individuals receive appropriate mental health services after admission to a skilled nursing facility] was completed correctly for 4 of 6 residents (Residents 6, 11, 210 and 23) reviewed for PASARR accuracy. This failure placed the residents at risk for not receiving appropriate mental health services.

Inspectors wroteBased on interview and record review, the facility failed to provide medically related social services (SS) that met the needs of residents in the areas of Notice of Medicare Non-Coverage (NOMNC- a required notice to Medicare beneficiaries to inform them when their Medicare covered services were ending, and of their right to appeal) for 1 of 3 residents (Resident 215). The facility failed to provide Advanced Beneficiary Notices (ABN- a notice to Medicare beneficiaries informing them of the cost of continued Medicare covered services and services that may not be covered) for 3 of 3 residents (Residents 50, 52 and 215). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain cleanliness of the kitchen environment to ensure food was stored, prepared and served under sanitary conditions for 1 of 1 kitchen and I of 3 ice machines reviewed for food safety. These failures placed residents at risk for potential food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse/neglect was reported to the State Agency in the required 24-hour time frame, for 1 of 1 resident (Resident 28) reviewed for abuse/neglect. Resident 28 was found with significant bruising to their left hand and forearm. Failure to report abuse/neglect in a timely manner placed the resident at risk for additional abuse.

Inspectors wroteBased on observation, interviews and record review, the facility failed to thoroughly investigate an allegation of abuse which resulted in a significant bruise of unknown origin for 1 of 1 resident (Resident 28) reviewed for abuse. This failure placed residents at risk for unidentified abuse, neglect, and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice to the resident and their representative of the facility's intention and justification for the discharge of 2 of 2 residents (Residents 39 and 55) reviewed for facility-initiated discharges. Additionally, the facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long Term Care (LTC) Ombudsman (a person that advocates for residents in nursing homes). This failed practice disallowed the resident and/or their representative an opportunity to fully understand the rationale and resident rights associated with the discharge. [...]

Inspectors wroteBased on interview and record review, the facility failed to issue a written notice of bed-hold (holding or reserving a resident's bed while the resident was absent from the facility) at the time of hospital transfer for 2 of 2 residents (Residents 39 and 55) reviewed for hospital transfers. This failure placed residents at risk for lack of knowledge regarding their right to hold their bed and any monetary charges associated with the bed-hold while in the hospital.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement an effective discharge planning process that addressed the resident's goals and needs and involved the resident and/or their representative and the interdisciplinary team [(IDT) a group of healthcare professionals from different disciplines to help residents receive the care they need] for 2 of 3 residents (Resident 208 and 38) reviewed for discharge planning process. The failure to develop and implement a plan consistent with the resident's needs and expressed discharge goals, placed the residents at risk for decreased self-worth and dissatisfaction with their living situation.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure 2 of 2 residents (Residents 11 and 10) reviewed for dependence with activities of daily living received care and services to meet their elimination needs. Residents 11 and 10 had specific care directives for toileting programs and did not receive timely assistance as required. This failure placed the residents at risk for incontinence unmet care care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide services and assistive devices to maintain vision abilities for 1 of 1 resident (Resident 23) reviewed for vision. The failure to provide vision care and assistive devices placed the resident at risk for worsening vision.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who were trauma survivors received culturally competent, trauma-informed care and services in accordance with professional standards of practice for 1 of 1 resident (Resident 23) reviewed for mood and behavior. This failed practice placed residents at risk for unidentified triggers, re-traumatization and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Staff AA, Licensed Practice Nurse (LPN), had the specific competencies and skill sets, which included documented demonstration, necessary to safely and efficiently perform care for residents' needs for intravenous [(IV) a soft, flexible tube placed inside a vein, usually in the hand or arm] medication administration for 1 of 2 residents (Resident 208) through a Peripherally Inserted Central Catheter [(PICC) - a thin, soft tube that is inserted into a vein in the arm, leg, or neck for long-term administration of antibiotics, medications, nutrition, and blood draws] line. This failure placed residents at risk for adverse outcomes related to medication administration and unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 2 of 2 medication storage rooms (East Hall and [NAME] Hall) was free from expired medications. This failed practice placed the residents at risk for receiving expired medication and/or experiencing compromised or ineffective medications.

Inspectors wroteBased on observation, interviews and review of records, the facility failed to thoroughly investigate an allegation of potential neglect and unwitnessed falls which resulted in substantial injuries to 3 of 3 residents (Residents 2, 3, and 4) reviewed for incidents and accidents. Failure to conduct thorough investigations to identify a root cause placed residents at risk for unidentified neglect, lack of corrective action and/or recurrent falls with injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the ability to exercise self-determination related to aspects of life in the facility that were significant to the resident, including the frequency of bathing for 2 of 4 residents (Resident 5 and 6) reviewed for choices. The failure to allow residents to choose how often to bathe placed the residents at risk for hygiene concerns, decreased self-worth and powerlessness.

Inspectors wroteBased on interviews and record review the facility failed to ensure an allegation of neglect was reported to the State Agency as required for 1 of 3 residents (Resident 2) reviewed for neglect. Failure to report allegations of neglect placed residents at risk for further neglect.

Inspectors wroteBased on interview and record review, the facility failed to follow and/or clarify physician orders for 1 of 4 residents (Resident 1) reviewed for services provided met professional standards of practice. This failure placed the resident at risk for negative health outcomes and unmet care needs.

Inspectors wroteBased on interviews and record review, the facility failed to have the State Reporting Log (method used by facilities to report incidents of possible abuse, neglect, abandonment, mistreatment, injuries of unknown source, evacuation, disasters/major outbreaks, unexpected death/suicide, personal and/or financial exploitation, or misappropriation of resident property in nursing homes) accessible to State investigators upon their request. This failed practice placed all residents at risk for unidentified abuse and neglect.

Inspectors wroteBased on interview and record review the facility failed to make a comprehensive assessment of each resident's functional capacity for 4 of 4 residents (Residents 269, 271, 219, and 220) reviewed for comprehensive assessments and timing. This failure placed the residents at risk of not having comprehensive care, not having appropriate services provided, and placed the residents at risk of their needs and preferences not being identified and care-planned for implementation.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan within 48 hours of admission that documented resident specific initial goals and treatment plans for 3 of 3 newly admitted residents (Residents 269, 271, and 219) to ensure continuity of care upon admission. The failure to develop baseline care-plans that meet all the requirements placed the residents at risk of unmet care needs, a delay in care and services and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plans (CP), in a timely manner, to address anticoagulant (a high-risk, blood thinning medication) and psychotropic (a drug taken to exert an effect on the chemical makeup of the brain and nervous system) medication use for 3 of 7 residents (Resident 169, 219, and 220) reviewed for care planning. This failure placed residents at risk for unrecognized adverse side effects (ASE), unmet psychosocial well-being and care needs, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure care plans (CP) were reviewed and revised to identify the changing needs for 3 of 7 residents (Residents 63, 21, and 34) reviewed for care plans. Areas of change were identified as psychotropic medication (a drug taken to exert an effect on the chemical makeup of the brain and nervous system) use, hospice services, and discharge planning. This failed practice put residents at risk for unidentified/unmet care needs, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to post the location of the survey results and failed to ensure survey results were accessible to residents for 5 of 7 residents (Resident 48, 24, 22, 55, and 52) who attended resident council meeting on 09/11/2023. This failure prevented residents, family members and visitors from exercising their right to review and access past survey results and the facility's plans of correction to evaluate the quality of care provided by the facility.

Inspectors wroteBased on interview and record review the facility failed to provide or have processes in place to assist with the development of Advanced Directives (AD) for 3 of 6 residents (Residents 60, 22, and 219) reviewed for Advanced Directives. This failure placed the residents at risk for not having the opportunity to make their healthcare preferences and/or decisions known.

Inspectors wroteBased on observation, interview and record review the facility failed to comprehensively assess and monitor the need for a physical restraint (any physical, mechanical device or equipment that limits a residents freedom of movement) by applying bolsters under the mattress elevating the bed to prevent the resident from getting out of bed, for 1 of 1 resident (Resident 26) reviewed for physical restraints. Additionally, the facility did not obtain a consent or identify the need for the restraint to ensure the least restrictive intervention was utilized. This failure placed the resident at risk for injuries and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change in status assessment for 2 of 2 residents (Residents 21 and 30) reviewed for comprehensive assessments. Failure to complete significant change of status care assessments placed the residents at risk for not receiving the care and services they required.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure 1 of 3 residents (Resident 6), reviewed for pressure injuries, received necessary care and services consistent with professional standards of practice to prevent a pressure injury from developing or worsening. The facility did not follow Resident 6's care plan interventions for positioning which placed the resident at risk to develop new pressure injuries or delay healing and worsening of their current pressure injuries.

Inspectors wroteBased on interview and record review, the facility failed to adequately supervise and initiate interventions for an exit seeking resident for 1 of 1 resident (Resident 49) reviewed for accidents. The failure to identify preventative measures resulted in the resident getting outside of the building and placed the resident at risk for re-elopement, accidents/hazards, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 2 residents (Resident 22 and 63) reviewed for respiratory care and treatment, received appropriate oxygen services consistent with professional standards of practice. Failure of the facility to ensure oxygen delivery was provided according to physician orders, monitored respiratory status, and maintained oxygen equipment, placed residents at risk of unmet needs, discomfort, and secondary medical complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor for adverse side effects (ASEs), initiate interventions, or identify adequate indications of use for anticoagulant (a high-risk, blood thinning medication) medications for 2 of 3 residents (Resident 63 and 64) reviewed for anticoagulants. Residents 63 and 64 did not have monitoring, or interventions. Resident 63 did not have an adequate indication of use. This failed practice caused the potential for residents to receive unnecessary medications, experience unidentified symptoms and risks, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to provide adequate monitoring and follow up with residents receiving psychoactive medications (medications that alter brain function related to perception, mood and behavior) for 3 of 5 residents (Resident 26, 22 and 49) reviewed for unnecessary medications. The facility failed to provide adequate monitoring for adverse side effects (ASE's) for changes in psychoactive medications for Resident 26. Additionally, the facility failed to have physician documented rationale for antianxiety medications used beyond 14 days for Resident 22 and 49. These failures put the residents at risk for adverse outcomes related to the use of psychoactive medications.

Inspectors wroteBased on interview and record review the facility failed to establish an effective communication process to ensure hospice services were delivered for 1 of 1 resident (Resident 220) reviewed for hospice services. This failure placed the resident at risk for diminished end of life care, hospice management and overall quality of care.