Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Washington Healthcare Center during CMS and state inspections, most recent first.
A facility failed to maintain a clean, safe, and homelike environment for multiple residents. A resident’s call light was repeatedly out of reach and dirty, several rooms had stained walls, dirty mattresses, worn linens, and broken or debris-covered equipment, and one bathroom had detached non-skid tape plus a grab rail stained with feces and a strong odor. Tube feeding supplies were left uncapped, meal cart drinks were left uncovered, and gnats were observed around residents, rooms, and food items.
Two residents did not receive needed ADL assistance as documented and observed. One dependent resident with a G-tube, severe ID, and Down Syndrome had dry, cracked lips, heavy oral secretions, plaque/tartar, and dental findings of poor oral hygiene and severe gingivitis, while a CNA reported using an oral swab instead of a toothbrush because brushing caused bleeding. Another resident with dementia and osteoarthritis repeatedly remained unshaven with overgrown hair and beard despite stating he wanted to stay clean shaven and preferring a professional barber or beautician.
A resident with schizophrenia and a history of TBI had repeated episodes of tearfulness, hallucinations, delusions, exit-seeking, and distress after moving to the memory care unit. Staff documented redirection, phone calls to family, snacks, and other brief interventions, while observations showed residents often engaged in unscheduled activities and the resident reported spending most of her time lying in bed because few activities interested her. She also stated she could no longer make private phone calls from her room and had to use the front desk.
Limited Vegetarian Meal Variety: A resident with TBI and depression who was documented as vegetarian reported that the food was terrible and that he often received the same few items, such as grilled cheese or PB&J. Meal records and tray observations showed repeated breakfast, lunch, and dinner choices with limited variety, despite the resident's sister reporting a long-standing vegetarian diet and a preference for a wider range of meatless foods.
Failure to Offer Influenza Vaccination: The facility failed to offer the flu vaccine to two residents reviewed for immunization status. One resident had schizophrenia, asthma, and sleep apnea, and another had dementia, DM2, CKD, and anxiety. Their records lacked flu vaccine consent, and neither resident received the vaccine. The RCS could not locate the consents or documentation showing the vaccines were administered.
Failure to offer and document COVID-19 vaccination for a resident with Alzheimer's disease, HTN, major depression, and anxiety. The resident's record lacked both consent for the COVID-19 vaccine and documentation that the vaccine was administered, and the RCS stated she could not locate either item. Facility policy stated residents are to be offered the COVID-19 vaccine on admission based on vaccination history.
A resident with multiple complex conditions was admitted with a physician's order for weekly PICC line dressing changes and specific measurements. The facility failed to document or perform the required dressing change and assessments, as confirmed by record review and staff interviews, despite facility policy and physician orders.
The facility failed to address Resident Council concerns about call light response times effectively. Observations showed call lights were often ignored for over five minutes, with staff engaging in personal conversations or remaining seated. Despite reported staff education, documentation was incomplete, and the issue persisted.
A resident with cognitive impairments was disrespected by the Executive Director during a care plan meeting. The resident, who did not know the ED's name, addressed her as "you," leading to an aggressive response from the ED. The meeting ended abruptly, leaving the resident feeling disrespected and upset. Witnesses confirmed the ED's unprofessional behavior, and the facility's policy on resident dignity was not upheld.
A resident with cerebral palsy, severe intellectual disability, and Down syndrome was not engaged in a meaningful activity program according to her preferences. Observations showed she was left in bed in a dark room, with minimal engagement. Staff interviews revealed she was rarely taken out of bed or involved in activities, despite her previous enjoyment of social interactions. Her care plans were outdated and not revised to reflect her current needs, and the facility's policy on individualized programs was not effectively implemented.
The facility failed to secure medications for two residents, leading to potential accident hazards. A resident with impaired cognition retained an albuterol inhaler despite staff attempts to retrieve it, while another resident had unsecured potassium and folic acid pills in her room without a self-administration assessment. This indicates lapses in supervision and adherence to medication management protocols.
The facility failed to properly store medications, as observed in two medication carts. External medications were stored with internal ones, and several inhalers lacked opening dates. This contravened the facility's policy on medication storage and expiration.
A resident with multiple health conditions, including dementia and diabetes, did not receive a pneumococcal vaccination despite consent being given by her responsible party. The oversight was identified during a record review, and the Regional Director of Clinical Services acknowledged the failure to administer the vaccine.
Unsafe and Unclean Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for 7 of 7 residents with observed concerns. Resident 40’s call light was repeatedly observed out of reach and dirty, with built-up debris under peeling tape, and later remained out of reach on the floor. The same resident’s bedside table was also observed to be dirty and stained. During the observations, several gnats were seen flying around Resident 40’s head and in the bathroom. Resident 10’s fall mattress was observed dirty, stained, and covered with visible food crumbs and other unidentifiable substances, and the wall beside the bed was dirty with stains and smears on repeated observations. Resident 12’s mattress was peeling with a large central stain and discoloration around the edges, and the wall beside the bed was streaked with stains. Resident 5’s tube feeding pole was broken, missing a rolling wheel, leaning to one side, and covered with streaks, stains, and debris; the bed frame had spilled and dried clumps of feeding, and gnats were observed in the room. Resident 47’s fitted sheet was worn thin with small holes, Resident 20’s blanket was frayed and tattered, and Resident 51 stated linen was often out, especially fitted sheets, and what was available was worn and dingy. In another bathroom, a non-skid tape strip had detached and curled on the floor, the grab rail was wrapped in yellow tape with smeared feces visible, and a strong odor was present. Resident 5’s tube feeding and hydration kangaroo bags were left uncapped and open to the air, and meal cart beverages were poured in the hall with uncovered cups while gnats were present. Uncovered cups were later observed on Resident 40’s bedside table with more than 5 gnats on the rim and around the resident and table.
Failure to Provide Oral Hygiene and Maintain Facial Hair Preference
Penalty
Summary
Proper oral hygiene was not provided and maintained for a dependent resident who was NPO with a G-tube and diagnoses including cerebral palsy, severe intellectual disabilities, and Down Syndrome. On multiple observations, the resident’s lips were dry and cracked, with a thick, pasty or frothy buildup around the lips and gums, and plaque/tartar was observed on the teeth. An uncovered cup of blue liquid and an oral sponge were left on the bedside table, and two gnats were seen on the rim of the cup. A CNA stated they did not like to use a toothbrush because it caused the resident’s gums to bleed and instead used an oral swab dipped in mouthwash to clean the mouth. The resident’s record included dental findings of heavy plaque, poor oral hygiene, dry mouth, red and inflamed tissues, and severe gingivitis along the gumline, with instructions to brush twice daily and to try brushing along the gumline as long as the resident would allow. A second resident who required assistance with ADLs and had dementia and osteoarthritis was not maintained according to his stated facial hair preference. He was observed with an overgrown beard and hair and stated several times that he was upset he had not been shaved or had a haircut in over two weeks and that he normally kept his face clean shaven. Additional observations showed his hair and beard remained untrimmed on later dates. The record identified that he required assistance from one staff member for ADLs, and the documentation lacked evidence that arrangements had been made for him to be taken to a barber or beautician despite staff acknowledging his preference for a professional barber or beautician.
Failure to Provide Person-Centered Behavioral Health Programming
Penalty
Summary
The facility failed to provide appropriate, person-centered programming and treatment plans to support the highest practical level of psychosocial well-being for one resident with behavioral health concerns. Resident 11 had diagnoses including schizophrenia and a history of traumatic brain injury and was observed lying in bed, watching her roommate’s television, with a flat affect and low mood. She reported that she had been at the facility for about five months and had not had any problems so far. Record review showed repeated behavioral symptoms and distress after the resident was admitted and later moved to the memory care unit, including attempts to leave the facility, packing belongings to go to the front door, crying, yelling, hallucinations, delusions, tearfulness, and banging on the exit door. Staff interventions documented in the record included redirecting her, assisting her to call her daughter, offering snacks and drinks, and directing her back to her room. The resident also expressed that she wanted to go outside of the unit for activities and to play bingo and have snacks with everyone else, but she was offered activities on the unit instead and refused. Observations on the memory care unit showed residents participating in activities that were not the scheduled activity, including watching a cooking show on a tablet, watching TV, listening to soothing music, having a snack, and playing trivia. Resident 11’s activity log showed activities were logged only three times in July and offered eight times in August so far. During interview, Resident 11 stated she liked being in the LTC section better because she felt like she mostly lay in bed on the memory care unit and there were not many activities that interested her. She also stated that she could no longer make private phone calls from her room and now had to use the front desk.
Limited Vegetarian Meal Variety
Penalty
Summary
The facility failed to ensure a vegetarian resident received food variety and options that accommodated his dietary preferences. Resident 43, a long-term care resident on the memory care unit with diagnoses including traumatic brain injury and depression, had a diet order for a regular diet and was documented as vegetarian. He told staff that the food provided was terrible, that he could sometimes send meals back for something else, but often there was nothing else available because he was vegetarian. He also stated that most days he received either grilled cheese or a peanut butter and jelly sandwich for his entree. Observation and record review showed limited meal variety across multiple days. During lunch tray observation, Resident 43 received two grilled cheese sandwiches and two sides. Meal tickets from 8/5/25 through 8/12/25 showed repeated entrees such as scrambled eggs, cheesy eggs, grilled cheese, peanut butter and jelly, cheese and crackers, pasta with no meat, kidney beans with sauce, bean burrito, and peanut butter with celery. The resident's sister had previously told the RD that he had been vegetarian for 17 to 18 years and liked pizza, Asian, Thai, Indian foods, fruit, grains, vegetables, meatless products, and faux meat products. An LPN stated the facility was doing the best it could to get him appropriate meals, but there could have been more options.
Failure to Offer Influenza Vaccination
Penalty
Summary
The facility failed to offer the influenza vaccination to 2 of 5 residents reviewed for influenza vaccination status. Resident 11 had diagnoses including schizophrenia, asthma, and sleep apnea, but her record lacked consent for the influenza vaccination and she did not receive the vaccination. Resident 18 had diagnoses including dementia, type 2 diabetes mellitus, chronic kidney disease, and anxiety, but his record also lacked consent for the influenza vaccination and he did not receive the vaccination. During interview, the Regional Clinical Specialist stated she could not find the consents or where the residents were administered the vaccinations. A facility policy titled, Influenza (Flu) Vaccination (Resident), stated that current and newly admitted residents will be offered the influenza vaccine unless contraindicated or already immunized during the time period.
Failure to Offer and Document COVID-19 Vaccination
Penalty
Summary
The facility failed to offer the COVID-19 vaccination to one resident, identified in the record review as Resident 15. The resident had diagnoses including Alzheimer's disease, hypertension, major depression, and anxiety. Her record did not contain a consent to administer the COVID-19 vaccine and also lacked documentation that the vaccine had been administered. During interview, the Regional Clinical Specialist stated she could not find the consent or any documentation showing the resident received the COVID-19 vaccination. The facility policy provided stated that on admission, residents are to be offered the COVID-19 vaccinations based on their vaccination history.
Failure to Complete PICC Line Dressing Change and Required Assessments
Penalty
Summary
A deficiency occurred when the facility failed to follow a physician's order for a resident who was admitted with multiple complex medical conditions, including a colostomy infection, osteomyelitis, diabetes mellitus type II, necrotizing fasciitis, an indwelling catheter, an ostomy, an unstageable pressure ulcer, and a peripherally inserted central catheter (PICC) for intravenous medications. The physician's order required the PICC dressing to be changed every seven days with a transparent dressing, and for the nurse to measure both the PICC catheter length and the upper arm circumference as part of the care protocol. Record review revealed that there was no documentation in the electronic treatment administration report (eTAR) that the PICC dressing had been changed or that the required measurements were completed as ordered. Interviews confirmed that the dressing had not been changed during the resident's stay, and the DON was unaware of the missed dressing change. Facility policy required these actions upon admission and at specified intervals, but the clinical record only noted that the dressing was clean, dry, and intact, without evidence of a dressing change or measurement completion.
Failure to Address Call Light Response Concerns
Penalty
Summary
The facility failed to address Resident Council Grievance concerns regarding call light wait and response times effectively and in a timely manner. Observations revealed multiple instances where call lights were illuminated, flashed, and alarmed at the nurse's station for over five minutes without being addressed by staff. In one instance, a resident was heard yelling for assistance repeatedly, and it was only after a visitor intervened that staff responded. Another resident was found waiting for morning medications, and the Executive Director had to step in to address the concern. Additionally, there were instances where staff were observed engaging in personal conversations or remaining seated at the nurse's station while call lights were active, indicating a lack of prompt response to residents' needs. The Resident Council Meeting minutes indicated ongoing complaints about call light response times, with residents reporting long wait times during multiple meetings. Despite follow-up forms indicating that staff education and in-service training were provided to address these concerns, the documentation was incomplete. The In-Service binder lacked detailed records of what was reviewed during the training sessions, and there were attendance logs without summaries or titles of the in-services. The Regional Director of Clinical Services acknowledged the lack of documentation, attributing it to the previous Director of Nursing's failure to maintain records. The facility's policy on Resident Council emphasized the importance of addressing concerns raised during meetings, but the deficiency in call light response times persisted.
Resident Dignity and Respect Violation During Care Plan Meeting
Penalty
Summary
The facility failed to ensure that a resident, referred to as Resident B, was treated with respect and dignity during a care plan meeting. Resident B, who has mild cognitive impairment, dementia, and depression, expressed that the Executive Director (ED) had hurt her feelings and made her uncomfortable during the meeting. The incident occurred when Resident B attempted to address the ED with a concern, but the ED interrupted her, pointed a finger in her face, and demanded respect. This interaction left Resident B feeling disrespected and embarrassed, leading her to cry after the meeting. During the care plan meeting, Resident B was accompanied by the Social Service Director, the Minimum Data Set Coordinator, and her best friend on speakerphone. The ED was called to address additional care concerns. When Resident B addressed the ED as "you" due to not knowing her name, the ED took offense and responded aggressively, which escalated into a verbal altercation. The ED ended the meeting abruptly, leaving Resident B feeling disregarded and upset. Witnesses indicated that the ED's tone was aggressive and unprofessional, and Resident B's friend confirmed that the ED's actions were inappropriate. Resident B's medical records showed no history of behavioral issues towards staff, and her care plan lacked documentation of any such concerns. The facility's policy on Residents' Rights emphasizes the right to a dignified existence and to be treated with respect, which was not upheld in this instance. The incident was part of a complaint investigation, highlighting a deficiency in the facility's adherence to its own policies regarding resident dignity and respect.
Failure to Engage Resident in Meaningful Activities
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 3, was included and engaged in a meaningful activity program according to her routine and preferences. Observations over several days revealed that Resident 3 was consistently left in bed, in a darkened room, with minimal engagement or stimulation. She was observed staring at a blank wall, with no music or television on, and her personal items, such as a baby doll, were out of reach. Interviews with staff and other residents indicated that Resident 3 was rarely taken out of bed or involved in activities, despite her previous enjoyment of social interactions and activities. The Activity Director, who was relatively new to the facility, acknowledged that Resident 3 was on a one-to-one activity program but noted that she was never dressed or brought to activities. The Regional Director of Clinical Services and the Executive Director both indicated that there was no known reason for Resident 3 to remain in bed and that she had previously enjoyed socializing. The activity participation logs for Resident 3 showed a lack of variety and engagement, with only three types of activities recorded and minimal weekend engagement. Resident 3's care plans, which were outdated and not revised, indicated a need for individualized activity programming due to her inability to participate in daily programming. The care plans included interventions such as one-to-one visits and room decoration in a juvenile theme, but these were not updated to reflect her current needs and preferences. The facility's policy on wellness and enrichment emphasized the importance of individualized one-on-one programs, but this was not effectively implemented for Resident 3.
Failure to Secure Medications for Residents
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards by not securing medications for two residents. Resident E, who has severely impaired cognition and multiple diagnoses including Alzheimer's disease and COPD, was observed with an albuterol inhaler in her possession on multiple occasions. Despite attempts by staff to retrieve the inhaler, Resident E retained it in her pocket, indicating a lapse in supervision and medication security. The inhaler was eventually retrieved by the Interim Director of Nursing, but not before Resident E had access to it for an extended period. Similarly, Resident 12 was found with unsecured medications in her room, including a potassium pill on her over-the-bed table and folic acid pills in an unlabeled prescription bottle. Resident 12, who has diagnoses including CHF, COPD, and bipolar disorder, was keeping the potassium pill to take later and had additional folic acid pills stored in her room. The facility's policy requires a self-administration assessment for residents to keep medications in their rooms, which was not completed for Resident 12, indicating a failure to adhere to medication management protocols.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage practices, as observed during a survey of two medication carts. On the 300-hall medication cart, a hydrophilic wound care dressing, which is a topical ointment, was found stored alongside oral inhalers, indicating a failure to separate external and internal medications. Additionally, a lidocaine injectable solution was found without a label or date on the vial. Several residents' inhalers, including those for Residents 208, 21, and 46, were found without dates indicating when they were opened, which is a requirement for ensuring medication efficacy and safety. Similarly, the 100-hall medication cart also exhibited improper storage practices. A resident's diclofenac sodium gel was stored with oral inhalers, again failing to separate external from internal medications. Another resident's Ventolin inhaler was found without a date indicating when it was opened. The facility's policy on the storage and expiration of medications, which mandates that external use medications be stored separately from internal use medications and that medications be dated according to manufacturer guidelines, was not adhered to in these instances.
Failure to Administer Pneumococcal Vaccination
Penalty
Summary
The facility failed to administer a pneumococcal vaccination to a resident who had given consent to receive it. Resident 35, who had diagnoses including unspecified dementia, unspecified protein-calorie malnutrition, type 2 diabetes, and asthma, had a consent form signed by her responsible party on 3/26/24 for the pneumococcal vaccination. However, the vaccination was not administered as per the consent. This deficiency was identified during a record review on 7/11/24, when the Regional Director of Clinical Services acknowledged the oversight and indicated plans to schedule the vaccination.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Indianapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westside Retirement Village | 3 mi | ★★★★★ | 31 | 0 |
| Envive Of Indianapolis | 3 mi | ★★★★★ | 16 | 0 |
| Wellbrooke Of Avon | 3.4 mi | ★★★★★ | 5 | 0 |
| Brooke Knoll Village | 3.8 mi | ★★★★★ | 10 | 0 |
| Plainfield Health Care Center | 3.9 mi | ★★★★★ | 32 | 1 |
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