Washington Soldiers Home

Inspectors wroteBased on interview and record review the facility failed to ensure freedom from abuse, during a resident-to-resident altercation, for 1 of 3 residents (Resident 2) reviewed for resident abuse. This failure placed the residents at risk for injury, psychological harm, diminished feelings of safety and security, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to address identified risk factors for the development of pressure ulcers and implement preventative interventions timely for 1 of 4 sampled residents (Resident 3) reviewed for pressure related wounds. Resident 3 experienced harm when they developed two facility acquired pressure injuries after identified pressure prevention strategies, air mattress and heel protection boots, were not implemented timely as recommended. This failure placed residents at risk of development for pressure injury, medical complications, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure podiatry (the treatment of feet and their ailments) care and services were provided timely to avoid podiatric complications in residents with diabetes (elevated blood sugar) for 1 of 3 sampled residents (Resident 39) reviewed for foot care. Resident 39 experienced harm when they developed an avoidable foot wound and pain due to wearing ill-fitting shoes that prevented the resident from participating in therapy resulting in a decrease in strength from baseline and a slight functional decline when there was a delay in scheduling a podiatric shoe fitting. This failure placed residents at risk of discomfort, reduced ambulation and reduced participation in activities of daily life.

Inspectors wroteBased on interview and record review, the facility failed to have psychotropic medication (medications that affect a person's mental state) informed consents accurately completed prior to administering the medication for 1 of 5 sampled residents (Resident 8) reviewed for unnecessary medication use. This failure placed the resident and/or their legal representatives at risk for lack of knowledge to make an informed decision regarding the use of the medications and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure personal privacy was protected for 1 of 3 sampled residents (Resident 50) when reviewed for resident rights. This failure placed the resident at risk for embarrassment, a violation of their privacy, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a sanitary and homelike environment for 1 of 4 halls (100 hall) when reviewed for environment. Failure to ensure Resident 19's wheelchair left armrest was in good repair placed the resident at risk for unsanitary conditions and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide written bed hold notice at the time of transfer to the hospital for 2 of 4 sampled residents (Residents 93 and 5) when reviewed for hospitalization. This failure placed the residents at risk for lacking knowledge regarding their right to hold their bed while in the hospital and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the minimum data set (MDS, an assessment tool) accurately reflected the status for 3 of 19 sampled residents (Residents 6, 5, and 1) when reviewed for accuracy of assessments. This failure placed the residents at risk for unmet care needs, inaccurate medical record information, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to screen for mental health services on admission for 1 of 7 sampled residents (Resident 30) when reviewed for Pre-admission Screening and Resident Review (PASSAR, a mental health services screening tool). This failure placed the resident at risk for lack of mental health support, increase in adverse behaviors, decrease in mood, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure license nurses followed orders for applying a splint (device used to immobilize or stabilize a joint or protected body part) and prevalon boots (boots used to relieve pressure on heels) for 1 of 3 sampled residents (Resident 1) when reviewed for positioning. This failure placed the resident at risk for worsening mobility, medical complications, and diminished quality of life. Finding Included. Review of the EHR showed Resident 1 was admitted to the facility on [DATE] with diagnoses that include hemiplegia and hemiparesis following cerebral infarction (paralysis that affects only one side of the body after blood flow to the brain was interrupted), heart failure, dysphagia (difficulty swallowing food or liquids) and dementia (thinking and social symptoms that interfered with daily functioning). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and services to increase and/or prevent further decline for 1 of 3 sampled residents (Resident 39) reviewed for limited range of motion (ROM). This failure placed residents at risk for a functional decline, increased dependence on staff, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor and accurately document fluid restrictions or failed to follow up on a speech therapy referral for 2 of 6 sampled residents (Residents 2 and 3) when reviewed for nutrition and/or dialysis. These failures placed residents at potential risk for medical complications and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to act on the consultant pharmacist's medication regimen review (MRR) recommendations and to have clearly documented rationale for not following the recommendation for 1 of 5 sampled residents (Residents 8) when reviewed for unnecessary medication use. This failure placed the resident at potential risk for medical complications and a decreased quality of life.:

Inspectors wroteBased on observation, interview, and record review, the facility failed to schedule a follow up dental appointment and provide prompt dental services for 1 of 3 sampled residents (Resident 19) when reviewed for dental. This failure placed the resident at risk for continued dental problems and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the actual hours worked in the nursing staffing postings for 5 of 5 observed days during the survey period (08/21/2025, 08/22/2025, 08/25/2025, 08/26/2025, and 08/27/2025) when reviewed for nursing staff postings. This failure prevented the residents, family members, and visitors from exercising their rights to know the actual numbers of available nursing staff in the facility.

Inspectors wroteBased on interview and record review, the facility failed to identify an allegation of neglect and failed to report the allegation to the state agency with the required timeframe for 1 of 3 sampled residents (Resident 1) reviewed for reporting alleged violations. These failures placed the resident at risk for ongoing abuse/neglect, unmet needs and a decreased quality of life.

Inspectors wroteBased on observation and interview, the facility failed to provide food at an appetizing temperature for 1 of 1 tray line when reviewed for Kitchen Services. This failure placed residents at risk of lower nutritional intake, potential weight loss, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure 22 of 90 sampled residents (Residents 2, 8, 13, 14, 18, 23, 30, 34, 37, 40, 48, 59, 60, 62, 64, 71, 73, 74, 82, 85, 86 and 140) received physician ordered therapeutic diets or portion sizes. This failure placed residents at risk for medical complications, nutritional deficits and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to obtain or offer assistance in formulating or periodically checking if a resident had a healthcare advance directive (AD) for 1 of 17 sampled residents (Residents 78) reviewed for AD. This failure placed the resident at risk to be denied the opportunity to direct their health care if they were to become unable to make decisions or communicate their health care preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an incident of potential abuse, such as misappropriation of personal property, was identified as such and reported to law enforcement and the State Survey Agency as required for 1 of 4 sampled residents (Resident 37) reviewed for abuse. Failure to report allegation/incident of abuse placed the resident at risk for additional abuse and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and investigate possible misappropriation of personal property/abuse for 1 of 4 sampled residents (Resident 37) reviewed for abuse. Failure to thoroughly investigate an allegation/incident of abuse placed the resident at risk for additional abuse and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) assessment was accurately completed upon or prior to admission for 1 of 7 residents (Resident 71) reviewed for PASRRs and/or unnecessary medications. This failure placed the resident at risk for unidentified mental health care needs and a poor quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for 1 of 19 sampled residents (Resident 78) reviewed for quality of care. The failure to assess, obtain orders, monitor, and document the use of Resident 78's shrinker (an elastic sock used to control swelling, promote healing and assist in shaping an amputated/surgically removed leg) prior to use, placed the resident at risk for medical complications, unmet needs, and a poor quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide the necessary care and services for 1 of 3 sampled residents (Resident 57) when reviewed for ADL decline. Failure to obtain a wheelchair for Resident 57's use, placed them at risk for avoidable decline and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to consistently monitor and document bowel movements and implement the bowel program when needed for 1 of 1 resident (Resident 28) reviewed for bowel protocol. Additionally, the facility failed to initiate proper positioning, for 2 of 3 residents (Resident 12 and 52) when reviewed for positioning and mobility. These failures placed the residents at risk for worsening conditions, discomfort, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary supervision and safety monitoring for 1 of 4 residents (Resident 28) reviewed for accidents. This failure placed the resident and the facility at risk for possible fire and serious injury related to an inaccurate smoking safety assessment.

Inspectors wroteBased on observation, interview and record review the facility failed to monitor and manage issues with pain for 1 of 2 residents (Resident 67) reviewed for pain management. Failure to monitor Resident 67's pain levels placed the resident at risk for uncontrolled pain and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure as needed (PRN) psychotropic medications (affecting the mind) were limited to 14 days for 1 of 5 sampled residents (Resident 59) when reviewed for unnecessary medications. This failure placed the residents at risk for receiving unnecessary psychotropic medication, avoidable medication side effects, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician orders were followed for 1 of 5 residents (Resident 66) reviewed for Unnecessary Medication Use. This failure placed the residents at risk for medical complications and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure sufficient services were provided for 1 of 2 residents (Resident 53) reviewed for Indwelling Urinary Catheter (a catheter/tube inserted into the bladder and left in place to drain urine) and Antibiotic Use. Failure to ensure Resident 53's urology (the branch of medicine concerned with the function and disorders of the urinary system) referral was implemented placed the resident as risk for further complications, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor the dialysis access site and follow up on dialysis center recommendations for 1 of 1 resident (Resident 62) reviewed for Dialysis. This failure placed the resident at risk for medical complications and a decreased quality of life.