Washington Care Center

In the surveyor’s words

From the most serious findings on record at Washington Care Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF835Aug 10, 2022

  Based on observation, interview and record review the Administration failed to utilize resources to operate the facility with functional essential equipment and infrastructure, and for fire watch (a tour of the entire facility to ensure there is no fire or smoke in the facility) conducted every 15 minutes throughout the nursing facility, which encompasses three floors, five units, and 139 current residents, while the automatic and manual fire alarm system was not functional, as directed by the State Fire Marshal. […]

• Immediate jeopardy, widespreadF880Jan 22, 2021

  Based on observation, interview, and record review, the facility failed to ensure 17 of 18 staff members (Staff C, D, E, F, G, H, I, J, K, L, M, N, O, P, Q, R, and S) consistently implemented the facility's written infection control policies and procedures and follow standards of practice related to proper use of required Personal Protective Equipment (PPE), and the required isolation/transmission-based precautions when providing care and services to residents with known or suspected COVID-19 infection. Additionally, the facility failed to ensure [MEDICATION NAME] visitors were notified and educated of infection control practices /expectations while visiting in the facility with COVID-19 outbreak. These failures constituted a situation of an Immediate Jeopardy (IJ). […]

• Immediate jeopardy, patternF607Mar 8, 2022

  Based on interview and record review, the facility failed to implement their abuse and neglect policies. Facility failure to identify, investigate, suspend suspected staff, rule out allegations of abuse, and effectively train staff on abuse prevention left all residents at risk for abuse, and psychosocial harm. An Immediate Jeopardy (IJ) was called on 03/04/2022 at 10:00 AM related to CFR 483.12 F-607, Develop/Implement Abuse/Neglect Policies. The IJ was removed on 03/08/2022 with a validation date of 03/08/2022 at 12:23 PM when an on-site inspection confirmed the facility implemented their removal plan by providing training to staff, interviewing all residents and suspending staff of concern. Refer to: F-600 Findings included . […]

• Immediate jeopardy, isolatedF600Mar 8, 2022

  Based on interview and record review, the facility failed to ensure one supplemental resident (Resident 176) reviewed for abuse was free from abuse related to the facility's failure to susupend staff when Resident 176 accused staff of abuse. This failure increased the likelihood of ongoing abuse and psychosocial harm. An Immediate Jeopardy (IJ) was called on 03/03/2022 at 6:30 PM related to CFR 483.12 F-600, Freedom from Abuse, Neglect and Exploitation. The IJ was removed on 03/08/2022 with a validation date of 03/08/2022 at 12:23 PM when an on-site inspection confirmed the facility implemented their removal plan by providing training to staff, interviewing all residents and suspending staff of concern. Refer to: F607, Develop and Implement Abuse and Neglect Policies. Findings included . […]

• Actual harm, isolatedF689Sep 18, 2025

  Based on observations, interviews, and record review, the facility failed to ensure each resident received assessed level of supervision and assistance to prevent accidents for 1 of 4 sampled residents (Resident 1) reviewed. Resident 1 experienced harm when they fell out of a mechanical lift without the assessed two caregiver assistance, landed on the floor, and sustained a traumatic brain injury (TBI), with multiple areas of bleeding in the brain, upper neck fracture and facial fractures. This failure placed other resident at risk that required assistance of two care givers and a mechanical lift for their Activities of Daily Living (ADLs). […]