Washington Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684May 26, 2023

  A. Based on observations, interviews and record review, the facility failed to ensure non-pressure wounds on a resident's toes were treated in a timely manner and failed to follow up on an arterial doppler causing a delay in treatment of the wounds which resulted in osteomyelitis, gangrene, and cellulitis for 1 of 3 reviewed for quality of care (Resident 45). B. Based on observation, interview, and record review, the facility failed to ensure residents had appropriate skin assessments and interventions in place to address non-pressure wounds for 2 of 3 residents reviewed for skin management (Residents 31 and 21). The immediate jeopardy began on 4/25/23 when Resident 45 was noted to have developed new wounds on his left and right toes. No treatments were ordered until 4/27/23. […]

• No harm, potential for more than minimal, widespreadF689May 26, 2023

  Based on observation, interview, and record review, the facility failed to ensure hot water temperatures were safe for 4 of 7 resident rooms reviewed for excessive hot water temperatures, and failed to ensure a resident who was at risk for falls with a history of repeated falls had appropriate fall interventions in place to prevent the potential for additional falls (Resident 2). Findings include: 1. During a tour with the Maintenance Supervisor, on 5/21/23 at 2:14 p.m., several resident rooms were checked for excessive hot water temperatures in resident bathrooms. a. room [ROOM NUMBER] water temperature was 125.3 degrees Fahrenheit (F). b. room [ROOM NUMBER] water temperature was 133.1 degrees F. c. room [ROOM NUMBER] water temperature was 128.4 degrees F. d. […]

• No harm, potential for more than minimal, patternF584Aug 12, 2025

  Based on observation, interview, and record review, the facility failed to maintain a safe, clean, comfortable, and homelike environment for 7 of 7 residents who had observed concerns (Residents 40, 10, 12, 5, 47, 20, and 51).Findings include:1. On 8/6/25 at 10:10 a.m., Resident 40's call light was observed out of reach, wrapped on top of the bedside dresser. The cord was visibly dirty with stains and built-up debris under peeling tape. On 8/8/25 at 10:00 a.m., Resident 40's call light remained out of reach, hung over the call box on the wall. The cord remained dirty. On 8/11/25 at 9:31 a.m., Resident 40's call light was observed hung out of reach on the call box, the cord remained dirty. On 8/12/25 at 10:25 a.m., Resident 40's call light remained out of reach and rested on the floor. […]

• No harm, potential for more than minimal, patternF565Jul 11, 2024

  Based on observations, interviews and record reviews, the facility failed to ensure Resident Council Grievance concerns related to call light wait and response times were addressed in a timely and effective manner to prevent ongoing concerns. This deficient practice had the potential to affect 10 of 53 residents who attended the Resident Council Meeting and complained on behalf of all 53 residents who resided in the facility. Findings include: On 7/9/24 at 9:36 a.m., the call light for room [ROOM NUMBER] was observed. It was illuminated, flashed and alarmed at the nurse's station. Several staff members passed the light. On 7/10/24 at 11:00 a.m., Resident 35 was heard as she yelled out, Nurse! over and over. […]

• No harm, potential for more than minimal, patternF761May 26, 2023

  Based on observation, interview, and record review, the facility failed to ensure a medication cart remained locked while unauthorized residents and visitors passed it for 1 of 1 random observation, and further failed to ensure a resident did not have medications in his room without a self-administration assessment for 1 of 1 resident reviewed for self-administration assessments (Resident 17). Findings include: 1. On 5/24/23 at 9:42 a.m., Licensed Practical Nurse (LPN) 52 was observed removing a 3 milliliter (mL) albuterol nebulizer treatment medication for Resident 17. She did not lock the medication cart when she walked away and off the unit. There was no nurse in line of sight of the cart, the nurse's station was empty. […]