Washington Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF761Nov 7, 2024

  Based 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. Findings included: During a concurrent interview and observation of medication administration on 11/05/2024 at 7:02 AM and 7:09 AM, Registered Nurse (RN) 1 left medication cart labeled Lower 200 unlocked and out of her view in the hallway and entered a resident's room to administer medication. RN 1 stated the medication cart should be locked and that she forgot. […]

• No harm, potential for more than minimal, isolatedF689Jun 23, 2026

  Based 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. […]

• No harm, potential for more than minimal, isolatedF641Nov 7, 2024

  Based 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. Findings included: 1. An Admission Record indicated the facility admitted Resident 78 on 06/25/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of encounter for other orthopedic aftercare. A quarterly MDS, with an Assessment Reference Data (ARD) of 09/30/2024, indicated Resident 78 was administered an anticoagulant medication in the last seven days. […]

• No harm, potential for more than minimal, isolatedF880Nov 7, 2024

  Based 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. Findings included: An Admission Record revealed the facility admitted Resident 2 on 02/27/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of encephalopathy, sepsis, enterococcus, methicillin resistant staphylococcus aureus infection and gastrostomy status. […]

• No harm, potential for more than minimal, isolatedF600Oct 27, 2021

  Based on observation, interview, and record review, the facility failed to supervise one of two residents (Resident 2) to prevent Resident 2 from hitting Resident 1 on the forehead. The failure to supervise Resident 2, who had increasing behaviors of physical aggression, and failure to protect residents from Resident 2's physical aggression, resulted in a small bump and bruise to Resident 1's forehead, and had the potential to result in more serious injury. Findings: A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 4/7/21, indicated Resident 1 had entered the facility in 2014. […]