Washington CTR for Aging SVCS

In the surveyor’s words

From the most serious findings on record at Washington CTR for Aging SVCS, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Jul 11, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF689Jul 16, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF600Sep 14, 2023

  Based 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. […]

• Actual harm, isolatedF689Dec 9, 2022

  Based on observation, record review, and staff interviews, for three (3) of 11 sampled residents, the facility's staff failed to ensure that residents received adequate supervision to prevent falls. Subsequently, three (3) residents had unwitnessed falls and sustained injuries. (Residents' #3, #4, and #7) Actual harm was determined for residents' #3, #4, and #7. The findings included: 1. Facility staff failed to provide adequate supervision to Resident #3 who had two unwitnessed falls. Resident #3 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbance, Cerebral Vascular Accident, Type 2 Diabetes Mellitus, Dizziness and Giddiness (feeling of being unbalanced and lightheaded) and Wandering. […]

• No harm, potential for more than minimal, patternF569Jul 16, 2024

  Based 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. The findings included: A review of the facility's trial balance dated 05/16/24 showed that Resident #28, #36, #25, #95, #12, #24, #67, #81, #87, #129, #94, #39, #105, #63, #90, and #32's accounts were above the $4000 limit. During a face-to-face interview conducted on 07/10/24 at 3:00 pm, Employee #24 (Resident Finance) stated that she sent letters to the residents' representatives regarding their accounts, but she did not keep track of when the letters were sent. […]