Washington Odd Fellows Home

In the surveyor’s words

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

• Immediate jeopardy, patternF600Jul 27, 2022

  Based on observation, interview and record review, the facility failed to ensure three of three sampled residents (24, 58, 69) were free from abuse after the facility became aware of several staff to resident abuse allegations that were logged as grievances. Additionally, due to the facility's lack of identifying these occurrences as abuse allegations, they failed to immediately implement interventions toward the protection of residents (24, 58, 69) from further abuse when identified Staff (F, G) continued to work with unsupervised access to all residents from 06/19/2022 to 07/20/2022. […]

• Actual harm, patternF686Jul 27, 2022

  Based on observation, interview and record review, the facility failed to ensure prevention of pressure injury development, worsening of existing pressures injuries and prevent the development of additionally pressure injuries for three of four residents (74, 84 and 39) reviewed for pressure injuries. This failure caused harm to Resident (74) when their pressure injury worsened to a Stage IV (four) pressure injury to their leg/ calf, a worsened pressure injury to the right heel and a new pressure injury to the left heel which resulted in pain and discomfort and potentially other medical complications. Additionaly the facility failed to identify, assess and develope wound treatment orders in a timely manner for two of two residents (84 and 39). […]

• Actual harm, isolatedF684Jul 23, 2024

  Based on observation, interview, and record review, the facility failed to ensure treatment and care was provided in accordance with professional standards of practice and the comprehensive, person-centered care plan for 5 of 5 residents (Residents 54, 11, 38, 36, and 13) reviewed for quality of care, in the areas of constipation/urinary bladder assessment, fluid restrictions, and timely implementation of physician orders. Resident 54 experienced harm when they did not have a bowel movement for four days and did not have a timely urinary bladder assessment, that resulted in pain, constipation, a small bowel obstruction (a blockage in the intestines), and a urinary bladder infection that required hospitalization . […]

• Actual harm, isolatedF686Jul 23, 2024

  Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services to prevent the occurrence of an avoidable pressure ulcer (PU-injury to skin and underlying tissue resulting from prolonged pressure) and implement wound care and services timely to avoid worsening of a PU for 3 of 5 residents (Residents 48, 108, and 13) reviewed for PU's. Resident 48 experienced harm when the facility failed to follow physician orders to ensure healing of their avoidable Stage 4 PU (a full thickness tissue loss of tissue with exposed bone, tendon, or muscle) to their coccyx (tailbone) and obtain pain control measures during wound care. […]

• Actual harm, isolatedF689Jul 23, 2024

  Based on observation, interview, and record review, the facility failed to provide the assessed level of supervision required to prevent avoidable accidents for 1 of 1 resident (Resident 54) reviewed for falls with injuries. Additionally, the facility failed to identify active smokers, and the level of supervision required to smoke safely, for 3 of 3 residents (Resident 214, 216, and 212) reviewed for smoking. Resident 54 experienced harm when they fell while using their front wheel walker with a right sided platform attachment (a support that attaches to the walker to support the forearm and shoulder) when walking to the bathroom unsupervised that resulted in a laceration above the right eyebrow and fractured right ribs. […]