Washington Soldiers Home

In the surveyor’s words

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

• Actual harm, isolatedF686Aug 29, 2025

  Based on interview and record review, the facility failed to address identified risk factors for the development of pressure ulcers and implement preventative interventions timely for 1 of 4 sampled residents (Resident 3) reviewed for pressure related wounds. Resident 3 experienced harm when they developed two facility acquired pressure injuries after identified pressure prevention strategies, air mattress and heel protection boots, were not implemented timely as recommended. This failure placed residents at risk of development for pressure injury, medical complications, and diminished quality of life.Findings included . […]

• Actual harm, isolatedF687Aug 29, 2025

  Based on interview and record review, the facility failed to ensure podiatry (the treatment of feet and their ailments) care and services were provided timely to avoid podiatric complications in residents with diabetes (elevated blood sugar) for 1 of 3 sampled residents (Resident 39) reviewed for foot care. Resident 39 experienced harm when they developed an avoidable foot wound and pain due to wearing ill-fitting shoes that prevented the resident from participating in therapy resulting in a decrease in strength from baseline and a slight functional decline when there was a delay in scheduling a podiatric shoe fitting. This failure placed residents at risk of discomfort, reduced ambulation and reduced participation in activities of daily life. Findings included . […]

• No harm, potential for more than minimal, patternF804Jul 18, 2024

  Based on observation and interview, the facility failed to provide food at an appetizing temperature for 1 of 1 tray line when reviewed for Kitchen Services. This failure placed residents at risk of lower nutritional intake, potential weight loss, and a diminished quality of life. Findings included . On 07/15/2024 at 12:42 PM, Resident 71 stated Some of the food sucks because the meat is overcooked. On 07/15/2024 at 12:58 PM, Resident 37 stated, The food does not taste good here. On 07/15/2024 at 12:23 PM Resident 78 stated, The food is not very flavorful and could use some improvement. […]

• No harm, potential for more than minimal, patternF808Jul 18, 2024

  Based on observation, interview and record review the facility failed to ensure 22 of 90 sampled residents (Residents 2, 8, 13, 14, 18, 23, 30, 34, 37, 40, 48, 59, 60, 62, 64, 71, 73, 74, 82, 85, 86 and 140) received physician ordered therapeutic diets or portion sizes. This failure placed residents at risk for medical complications, nutritional deficits and a decreased quality of life. Findings included . <Therapeutic Diets> Review of lunch menu for 07/17/2024 showed the Regular diets would receive Italian Meatloaf, Lemon Herb Orzo, Garlic Bread, Roasted Asparagus and Marbled Cheesecake. Review of the lunch extension menu showed Easy to Chew, Soft and Bite Sized and Puree diets were to receive a wheat roll instead of garlic bread. […]

• No harm, potential for more than minimal, patternF758Feb 1, 2022

  Based on observation, interview and record review, the facility failed to ensure monitoring of potential side effects related to the use of psychoactive medications for three out of five residents (Residents 60, 36, and 16) reviewed for unnecessary medication use. The facility's failure to monitor orthostatic blood pressure (blood pressure taken while lying, sitting, and standing) related to use of antipsychotic medications placed the residents at risk for adverse side effects, medical complications and a diminished quality of life. […]