Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Kadima Rehabilitation & Nursing At Washington during CMS and state inspections, most recent first.
Failure to reorder a seizure medication timely for a resident with epilepsy, HTN, and anxiety. The eMAR showed Briviact 100 mg was awaiting pharmacy delivery, and an RN stated the meds did not arrive before the supply ran out. The DON confirmed the refill was not timely and the resident was sent to the hospital for evaluation and treatment.
Surveyors found that staff failed to follow physician orders and care plans for compression therapy and edema management for multiple residents with conditions such as CHF, lymphedema, CAD, atrial fibrillation, Alzheimer’s disease, and diabetes. One resident repeatedly assessed by a wound NP as needing AeroWrap compression had no corresponding physician order and no compression device in use despite visible leg edema. Several other residents had orders and care plan interventions for TED hose or ace wraps to be applied daily, yet TARs showed missing or incorrectly scheduled treatments, and observations on days when staff documented application revealed that residents were not wearing the ordered compression devices. One resident reported staff did not consistently apply or remove ace wraps, and another was observed with swollen legs while not wearing the ordered stockings, despite staff acknowledging the swelling.
The facility failed to provide sufficient nursing staff to meet residents’ daily needs and to respond promptly to call lights, resulting in multiple care concerns. A resident reported that staffing levels were low, sometimes with only four nurse aides for the entire building, and was observed with unmet grooming needs. Another resident stated they had urinated on themselves while waiting for staff to answer a call light, and others reported long waits for assistance, especially at night. A resident dependent on staff for ace wrap application and removal was observed with blood-soiled wraps and reported that staff did not consistently assist with this care or respond to call lights. Resident Council minutes documented ongoing concerns about lack of ice water, slow call light response, difficulty identifying assigned aides, and negative interactions with nursing staff. The administrator acknowledged that nursing staffing was insufficient to meet residents’ needs.
A resident with CHF, history of DVT, and chronic lymphedema was care planned for monitoring of SOB, chest pain, edema, and elevated B/P, and multiple NP and physician notes documented that the resident, on diuretics, needed outpatient follow-up with a lymphedema clinic. Review of the clinical record showed no order or attempt to schedule this follow-up appointment. In interviews, an RN and the Nursing Home Administrator confirmed that the resident did not receive the needed lymphedema clinic appointment, resulting in a deficiency under 28 Pa. Code 211.16(a) for failure to provide necessary medically-related social services.
The facility failed to post required contact information for APS, the State Agency, and the statement that residents may file a complaint with the State Agency in the area where postings were located. During observations in the lobby and hallways near the nursing units, the required agency name, address, email address, and phone number were not posted or accessible to residents or resident representatives. The NHA later confirmed the missing postings.
Failure to Offer and Review Advance Directives: The facility did not provide the opportunity for two residents to formulate an advance directive or complete periodic review of advance directive instructions. One resident had a POA and an old advance directive in the record, but the facility later documented no advance directive on file and no evidence of review with the resident or POA. The other resident had diagnoses including DM, HTN, and depression with a BIMS score of 13, but the record lacked an advance directive, review documentation, or evidence the resident was offered the opportunity to complete one.
The facility did not provide the required number of nurse aide (NA) hours on several day shifts, with actual staffing falling short of the mandated minimum based on the resident census. This was confirmed by the Nursing Home Administrator, who acknowledged the shortfall in NA coverage during the reviewed period.
The facility did not provide the required minimum of 3.2 hours of direct nursing care per resident per day over an eight-day period, as confirmed by staffing records and the Nursing Home Administrator.
The facility did not include all required elements in its grievance policy and failed to document, resolve, or provide responses to residents or their responsible parties for multiple grievances. Issues included missing personal items, concerns about cleanliness, staff conduct, and missed care, with incomplete or missing documentation and lack of communication regarding grievance outcomes.
The facility did not follow required procedures to report multiple residents' allegations of abuse and neglect, including verbal abuse by a physician, missed showers, lack of staff assistance, and rough handling by a nurse aide. Although these concerns were documented and known to facility leadership, they were not reported to the appropriate authorities as mandated by policy and state law.
Multiple residents did not receive timely assistance with ADLs, including missed showers, delayed call light responses, and lack of basic care such as fresh water and snacks. Facility records and resident council minutes confirmed ongoing issues with staff not providing scheduled care or completing rounds, and the DON acknowledged these failures.
The facility did not provide required transfer notices to the Office of the State Long-Term Care Ombudsman for the entire year of 2024. This was confirmed by the Nursing Home Administrator and identified through a review of the facility's policy and federal regulations, which require such notifications before transferring or discharging residents.
The facility failed to meet professional standards by not having a Registered Dietitian (RD) physically present to fulfill in-person duties such as participating in interdisciplinary meetings and monitoring Food Service operations. The RD worked remotely, relying on email communication with the Dietary Manager and nursing staff, which did not align with the job description requirements. The Nursing Home Administrator confirmed the deficiency, as the facility had been unable to fill the on-site RD position.
The facility failed to maintain a comprehensive water management program for Legionella, lacking essential documentation and control measures. The absence of logs for chlorine concentration and water temperature testing, along with the recent termination of the Maintenance Director, contributed to this deficiency. The Nursing Home Administrator confirmed the facility's non-compliance with infection control guidelines.
Kadima Rehabilitation and Nursing at Washington failed to provide residents and visitors with the means to file grievances anonymously. The only grievance box was located in front of the NHA's office, compromising anonymity, and no grievance forms or boxes were available on the nursing units. Interviews confirmed the lack of anonymous grievance options, violating the facility's grievance policy.
The facility failed to assess, document, and notify physicians of abnormal blood glucose levels for five residents with diabetes. Despite high or low CBG readings, necessary follow-up actions, including rechecking levels and notifying physicians, were not documented. Interviews with staff revealed inconsistencies in handling abnormal glucose levels, and the Director of Nursing confirmed these deficiencies.
The facility failed to assess three residents for safe smoking practices as required by their policy. Despite having medical conditions that necessitate regular reviews, these residents were not reassessed for smoking safety. The DON confirmed that no further assessments were completed, violating the facility's policy and regulatory requirements.
The facility did not conduct required criminal background checks before hiring a Dietary Aide and an RN, as mandated by their policy. A Human Resources employee mistakenly believed there was a 30-day grace period post-hire for these checks, leading to potential exposure of residents to unvetted staff.
A resident with diabetes received an incorrect dose of Lantus insulin because an LPN failed to prime the insulin pen before administration, as required by the manufacturer's guidelines. The facility's Director of Nursing confirmed the error, which deviated from the facility's medication administration policy.
The facility failed to meet the required nurse aide staffing levels, with shortages during the day, evening, and night shifts over a 21-day period. The Director of Nursing confirmed the facility's inability to provide the mandated nurse aide coverage, with no additional staff available to compensate for these deficiencies.
The facility failed to meet the required LPN staffing levels across various shifts over a 21-day period. During the day shift, the facility was short of the required LPNs on 13 days, with the census necessitating between 2.48 to 2.60 LPNs, but only 2.00 to 2.13 LPNs were provided. The evening shift was understaffed on 7 days, requiring 2.07 to 2.17 LPNs, but only 1.56 to 2.00 LPNs were available. The night shift also experienced shortages on 13 days, with the census requiring 1.55 to 1.60 LPNs, but only 0.25 to 1.25 LPNs were available.
The facility failed to provide the required number of LPNs per residents during various shifts and did not meet the mandated 3.2 hours of direct resident care per resident in a 24-hour period on multiple occasions. The DON confirmed these deficiencies, with PPD hours falling below the required threshold on several dates.
A resident with severe cognitive impairment and a history of exit-seeking behavior eloped from the facility unsupervised. The resident was found outside by staff retrieving personal food deliveries. Despite the door requiring a password, the resident claimed to have pressed buttons to exit. The facility failed to implement effective monitoring as per their policies, leading to this deficiency.
A resident with severe cognitive impairment and a history of exit-seeking behaviors managed to leave the facility, highlighting a deficiency in the facility's training program. The training did not adequately address the specific methods of elopement, despite the resident being care planned as an elopement risk.
The facility failed to maintain the confidentiality of residents' medical information by storing approximately 75 boxes of loose paper with resident information in an unsecured storage shed. This was against the facility's policy requiring secure, fire-protected, and waterproof storage for medical records. The Maintenance Director confirmed the storage was due to space issues, and the Nursing Home Administrator acknowledged the breach of confidentiality.
The facility failed to maintain a safe, clean, and homelike environment in the North Wing Nursing Unit and the main dining room. Observations revealed issues such as a hole in the floor, chipped paint, a cracked ceiling, a broken wall plug plate, unfinished drywall, and a soiled dining room floor. These deficiencies were confirmed by the Nursing Home Administrator and the Maintenance Director.
A resident with a history of diabetes and other medical conditions fell from bed due to neglect when a nurse aide failed to follow physician's orders requiring two staff for bed mobility. The resident expressed discomfort with the procedure, but the aide proceeded, resulting in the fall.
A resident with multiple health issues required two staff for bed mobility, but a nurse aide attempted care alone, leading to the resident's fall. Staff inconsistencies in accessing care information contributed to the incident, highlighting a failure in supervision and adherence to physician orders.
Failure to Reorder Seizure Medication Timely
Penalty
Summary
The facility failed to reorder medications in a timely manner for one resident with epilepsy, high blood pressure, and anxiety. The resident was re-admitted to the facility with these diagnoses, and the MDS dated 2/1/26 confirmed the diagnoses remained current. A physician order dated 7/22/25 directed Briviact 100 mg twice daily for epilepsy. Facility policy required medications to be reordered three to five days before they were needed, or seven days in advance for certain prescriptions, and the medication administration policy required documentation when a regularly scheduled dose was withheld or not given at the scheduled time. On 5/1/26, the eMAR showed Briviact 100 mg was awaiting medication from the pharmacy at 10:03 a.m. and again at 6:38 p.m. An on-call note later documented that an electronic prescription for Briviact 100 mg was entered at 9:46 a.m. that same day. During interview, an RN stated the resident's medications did not arrive before the supply ran out. The DON confirmed the facility failed to refill the resident's medication timely, and stated this resulted in the resident being sent to the hospital for evaluation and treatment.
Failure to Follow Physician Orders for Compression Therapy and Edema Management
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders and residents’ care plans, specifically related to compression therapy for edema and lymphedema management. One resident with heart failure, history of DVT, and lymphedema had repeated wound NP notes over several weeks stating the need for AeroWrap inelastic compression for all-day wear at 30–50 mmHg for lymphedema management, and the care plan was updated to reflect lymphedema. However, there was no corresponding physician order for AeroWraps or any compression device in the clinical record, and the resident confirmed she did not have compression stockings; observation showed edematous lower legs with sock indentations. Another resident with high blood pressure, heart failure, and diabetes had a care plan intervention for bilateral knee-high TED hose and a physician order to apply ace wraps to both lower extremities. The March treatment administration record (TAR) showed that an LPN documented application of ace wraps on a specific date, but observation that same day revealed the resident did not have the ace wraps on. A third resident with heart failure, atrial fibrillation, and lymphedema had a care plan and physician order for ace wraps to both lower extremities every morning from the base of the toes to one inch below the knee. The March TAR lacked documentation of ace wrap application on multiple dates, and the order was incorrectly scheduled for nighttime instead of morning. During observation, this resident had ace wraps in place with a large amount of blood on the wraps and reported that staff did not always apply them and did not assist with removal despite call light use. A fourth resident with coronary artery disease, atrial fibrillation, and a need for assistance with personal care had a care plan and physician order for bilateral below-the-knee TED hose to be applied in the morning and removed at night. The March TAR indicated an LPN had applied the wraps on a specific date, but observation that afternoon showed the resident was not wearing compression stockings. A fifth resident with Alzheimer’s disease, diabetes, and a need for assistance with personal care had a care plan and physician order for bilateral lower extremity TED hose to be applied every morning and removed at bedtime for edema. The March TAR lacked documentation of application on multiple consecutive days, and although the TAR showed application on a later date, observation that afternoon showed the resident was not wearing compression stockings; when the resident asked an RN how her legs looked, the RN responded that they were swollen as usual. The Nursing Home Administrator confirmed that the facility failed to follow physician orders for five of seven residents reviewed.
Insufficient Nursing Staff and Delayed Call Light Response Affect Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs and to respond to call lights in a timely manner, as required by facility policy. The Nursing Department Staff policy stated that sufficient personnel would be provided on a 24-hour basis to deliver nursing care in accordance with resident care plans, and the Call Light Response policy required staff to respond to call lights and resident requests in a timely manner. Multiple residents reported inadequate staffing and delayed care. One resident stated there was not sufficient staff and that sometimes only four nurse aides were available for the entire building; this resident was observed with facial hair on her chin, suggesting grooming needs were not being addressed. Another resident reported that staffing adequacy depended on which aides were on shift, and confirmed having urinated on themselves while waiting for staff to respond to the call light. Additional residents described prolonged call light response times, particularly at night, and one resident stated that staffing “could be more.” One resident who required ace wraps reported that staff did not always apply them and did not assist with removing them; during observation, this resident was noted to have ace wraps in place with a large amount of blood present on the wraps, and confirmed being unable to manage them independently and that call lights sometimes went unanswered. Resident Council minutes from two consecutive months documented concerns about ice water not being provided, call light response times, difficulty knowing which aide was assigned, and perceptions that nursing staff were not very nice. In an interview, the Nursing Home Administrator confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services necessary to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the affected residents.
Failure to Arrange Ordered Lymphedema Clinic Follow-Up
Penalty
Summary
The deficiency involves the facility’s failure to provide medically-related social services by not arranging a needed follow-up appointment with a lymphedema clinic for one resident. The resident was admitted with diagnoses including heart failure, a history of DVT, and lymphedema. An MDS dated 2/26/26 documented these conditions, and the care plan for high blood pressure and CHF directed staff to observe for signs and symptoms such as SOB, chest pain, edema, and elevated blood pressure. The care plan for actual/potential risk for skin integrity impairment was updated on 3/6/26 to include lymphedema. Multiple provider notes documented the need for a lymphedema clinic follow-up. A nurse practitioner’s note dated 2/24/26 listed lymphedema and specified that the resident, who was on diuretics, needed follow-up with a lymphedema clinic. A physician’s note dated 2/25/26 and another nurse practitioner’s note dated 3/3/26 both reiterated that the resident had chronic lymphedema, was on diuretics, and needed outpatient follow-up with a lymphedema clinic. Review of the clinical record showed no order for this appointment and no attempt to schedule it. In interviews, an RN confirmed the resident was not provided a follow-up appointment, and the Nursing Home Administrator confirmed the facility failed to schedule the follow-up, constituting noncompliance with 28 Pa. Code 211.16(a) regarding social services.
Failure to Post Required State Agency and APS Contact Information
Penalty
Summary
The facility failed to post required contact information for pertinent State agencies and advocacy groups, including Adult Protective Services (APS), the State Agency, and a statement that residents may file a complaint with the State Agency, in the one location where postings were observed on the first floor nursing unit. During observations on 1/29/26 at approximately 11:30 a.m. in the lobby and hallways in and around the nursing units, the required elements were not posted or accessible to residents or resident representatives, including the agency name, address, email address, and phone number for APS and the State Agency complaint statement. During rounds and an interview with the Nursing Home Administrator on 1/30/26 at 9:00 a.m., the NHA confirmed the facility failed to post the required information for APS and the statement that residents may file a complaint with the State Agency in the building.
Failure to Offer and Review Advance Directives
Penalty
Summary
The facility failed to provide the opportunity to formulate an advance directive or to conduct periodic review of advance directive instructions for two residents. Facility policy stated that periodic review of DNR orders would occur at least annually, and the record review showed that one resident had a POA for health care and an advance directive dated 1/3/02, but the facility documentation later indicated the resident did not have an advance directive on file and no copy had been provided to the facility. There was no evidence that periodic advance directive review occurred with the resident or the POA, and the Social Service Director confirmed the POA had not responded to mailed care conference invitations and had not been visiting for some time. For the second resident, the clinical record showed diagnoses of diabetes mellitus, hypertension, and depression, with a BIMS score of 13. The record failed to show an advance directive, evidence of periodic advance directive review, or documentation that the resident was given the opportunity to formulate an advance directive. The Social Service Director confirmed the resident and family had been invited to care conferences, but the facility could not provide documentation showing whether the resident or family attended in the past twelve months, although code status had been reviewed by staff in attendance. The NHA confirmed the facility failed to provide the opportunity to formulate an advance directive or conduct periodic review of instructions.
Failure to Meet Minimum Nurse Aide Staffing Requirements on Day Shift
Penalty
Summary
The facility failed to meet the required minimum nurse aide (NA) staffing levels on the daylight shift for six out of eight days during the period reviewed. Specifically, staffing documents showed that on multiple days, the actual NA hours provided were significantly below the hours required based on the resident census. For example, on days when the census ranged from 66 to 69 residents, the facility provided between 22.5 and 45 NA hours, while the required hours ranged from 49.5 to 51.75. This deficiency was confirmed by the Nursing Home Administrator during an interview, who acknowledged that the facility did not provide the mandated number of NAs on the specified shifts.
Plan Of Correction
1. The facility cannot correct the ratio of 1 NA to 10 residents on the daylight shift on six of eight days (6/23/25 through 6/25/25 and 6/28/25 through 6/30/25) as required. 2. The facility will ensure that nurse aide staffing ratios are met every shift. 3. The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5520 and the correct ratios. 4. In order to help to retain/attain sufficient staff for the facility, NHA will continue to focus on hiring qualified candidates as well as utilizing retention strategies. Facility will continue to utilize Indeed postings are being utilized and facility department heads are assisting with recruiting as needed per department. 5. The Nursing Home Administrator/designee will audit staffing daily for four weeks to ensure nurse aide staffing ratios are being met. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.
Failure to Meet Minimum Direct Nursing Care Hours
Penalty
Summary
The facility failed to meet the state-mandated minimum requirement of 3.2 hours of direct nursing care per resident per day over an eight-day period. Review of staffing documents and nursing schedules revealed that, from 6/23/25 through 6/30/25, the provided per patient daily (PPD) hours of direct care consistently fell below the required threshold, with daily PPDs ranging from 2.61 to 3.18. This deficiency was confirmed by the Nursing Home Administrator during an interview, who acknowledged that the facility did not provide the minimum required direct care hours on the specified dates. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency were provided in the report.
Plan Of Correction
The facility cannot correct that the minimum number of general nursing hours to each resident in a 24-hour period were not met on eight of eight days (6/23/25 through 6/30/25). 2. The facility will ensure that general nursing hours are met every shift. 3. The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5640 and ensuring general nursing hours to each resident are met each shift. 4. In order to ensure staffing is met, the facility will focus on recruitment and retention and continue to utilize Indeed. 5. The Nursing Home Administrator/designee will audit staffing daily for four weeks. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.
Failure to Document, Resolve, and Respond to Resident Grievances
Penalty
Summary
The facility failed to ensure that its grievance policy included all required elements and did not properly document, resolve, or provide responses to residents or their responsible parties for grievances. The policy lacked provisions for anonymous grievance filing, identification of a grievance official, the right to a written decision, immediate action to prevent further violations during investigations, mandatory reporting of certain violations, detailed written grievance decisions, appropriate corrective actions, and maintenance of grievance records for at least three years. These omissions were confirmed through review of the facility's grievance policy and interviews with facility leadership. Multiple concern forms reviewed for thirteen residents revealed that for eleven residents, key sections such as immediate actions, summary of findings, and corrective actions were left blank or incomplete. Questions regarding whether the concern was confirmed, if a written decision was requested, and whether the resident or responsible party was notified of the resolution were frequently unanswered. Signature lines for department heads and the NHA were often unsigned, indicating a lack of accountability and follow-through in the grievance process. Specific grievances included missing personal items such as clothing and money, concerns about room cleanliness, staff behavior, missed showers, and rough handling by staff. In several cases, documentation failed to show that the concerns were investigated or resolved, and there was no evidence that residents or their representatives were informed of outcomes. Interviews with facility leadership confirmed these deficiencies in both policy and practice.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to implement its policies and procedures for reporting allegations of abuse and neglect for five of twelve residents. According to the facility's own policy and state law, all suspected abuse or neglect must be reported to the appropriate authorities, including the Department of Health and the Area Agency on Aging. However, review of clinical records, concern forms, and interviews revealed that multiple allegations made by residents were not reported as required. One resident, with a history of diabetes, coronary artery disease, and fibromyalgia, reported verbal abuse by the Medical Director and stated she had informed multiple staff members. Despite this, there was no grievance entered on her behalf, and the allegation was not reported to the state agency. Other residents, all with BIMS scores indicating they were cognitively intact, reported issues such as missed showers, lack of assistance from staff, and rough handling by a nurse aide. These concerns were documented in facility records but were not reported to the appropriate authorities as allegations of neglect or abuse. Interviews with facility leadership, including the Nursing Home Administrator and Director of Nursing, confirmed that the facility was aware of these allegations but failed to follow through with mandated reporting procedures. The review of submitted reports to the state agency showed that none of these incidents were included, indicating a systemic failure to comply with both facility policy and state regulations regarding the timely reporting of suspected abuse and neglect.
Failure to Provide Timely ADL Assistance and Basic Care
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for eight out of sixteen residents, as evidenced by multiple resident interviews, review of facility documents, and grievances. Residents reported long call light response times, lack of assistance with personal care needs such as showers, and insufficient provision of basic necessities like fresh water and snacks. Several residents specifically mentioned that staff were often short-staffed and unable to meet their needs in a timely manner. Facility records showed missed or undocumented showers on scheduled dates for multiple residents, and grievances confirmed that some residents were not assisted as required, including one resident not receiving help from the overnight nurse aide until early morning hours. Resident Council minutes from three consecutive months further documented ongoing concerns, including lack of snacks, failure to empty catheter bags, and staff not completing rounds or providing care as expected. The Director of Nursing confirmed the failure to provide necessary ADL assistance for the affected residents. The facility's own policy required care to be provided as needed 24 hours a day to help residents attain and maintain the highest level of functioning, but this standard was not met for the residents identified in the report.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to comply with federal regulations regarding the notification of the Office of the State Long-Term Care Ombudsman before transferring or discharging residents. Specifically, the facility did not provide transfer notices to the Ombudsman for the entire year of 2024, as confirmed by the Nursing Home Administrator during an interview. This deficiency was identified through a review of the facility's policy on 'Transfer and Discharge' and the relevant federal regulations, which mandate that a copy of the transfer or discharge notice must be sent to a representative of the Ombudsman. The facility's policy indicated that no resident would be discharged without timely notification to the resident, responsible party, or authorized representative. However, the facility did not adhere to the requirement of notifying the Ombudsman, which is a critical step in the transfer or discharge process. This oversight was consistent across all months from January to December 2024, indicating a systemic issue in the facility's compliance with the notification requirements outlined in §483.15(c)(3).
Plan Of Correction
1. The facility will provide transfer notices to representatives of the Office of the Long-Term Care Ombudsman Division. The facility cannot retroactively address the concern identified during the annual survey. 2. The facility will send the discharge/transfer list to the state Ombudsman monthly. 3. The Nursing Home Administrator or Designee will re-educate the Director of Social Services on federal tag 0623. 4. The Nursing Home Administrator or Designee will complete an audit monthly for three months to validate the transfer/discharge list is completed and sent to the state Ombudsman monthly. 5. The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.
Deficiency in Registered Dietitian's On-Site Participation
Penalty
Summary
The facility failed to meet professional standards of quality as required by §483.21(b)(3) Comprehensive Care Plans. The deficiency was identified through a review of facility policies, job descriptions, clinical records, and staff interviews. It was determined that the facility did not adhere to acceptable standards of practice concerning the participation of the Registered Dietitian (RD) in interdisciplinary meetings, monitoring of Food Service operations, conducting resident interviews, and participating in the Quality Assurance and Performance Improvement (QAPI) program. The RD, Employee E6, worked remotely for eight hours per week and had not been physically present in the facility for over a year. This arrangement did not allow the RD to fulfill the in-person duties outlined in the job description, such as encouraging resident and family participation in care plans, maintaining liaison with families and residents, and attending departmental meetings. Interviews with the RD and other staff members confirmed the lack of in-person involvement by the RD. The RD, located out of state, relied on email communication with the Dietary Manager (DM) and nursing staff to address dietary issues. The DM confirmed that she handled in-person communication with residents, while the RD managed remote assessments and documentation. The Nursing Home Administrator acknowledged the facility's failure to have an RD on-site to participate in interdisciplinary meetings, monitor Food Service operations, or perform any in-person duties as required by the job description. This situation arose because the facility had been unable to fill the position for an on-site RD, and the current RD had accepted the role temporarily to assist the facility until a permanent solution could be found.
Plan Of Correction
1. The facility failed to have a Registered Dietitian on premises that participated in interdisciplinary meetings, monitor Food Service operations, or completed any in-person actions of the Registered Dietitian Job Description. 2. The Dietary Manager/Administrator/Designee will be educated by the NHA/Designee. 3. Registered Dietician will be hired for on the premises and will participate in interdisciplinary meetings, monitor Food Service operations, and complete any in-person actions of the Registered Dietitian Job Description.
Failure in Legionella Water Management Program
Penalty
Summary
The facility failed to maintain a comprehensive infection prevention and control program specifically related to water management for Legionella. The deficiency was identified through a review of the facility's Legionella policy, documentation, and staff interviews. The facility's policy, dated January 9, 2025, outlined specific actions for the prevention and investigation of Legionella cases. However, the facility did not adhere to these guidelines, as evidenced by the lack of a comprehensive water management program to monitor and control the potential development and spread of Legionella for the entire year from December 2023 to December 2024. The facility's water management plan lacked essential elements such as a log for Point of Use Disinfectant to measure and record chlorine concentration levels in the water. Additionally, there were no logs for the flushing of hot water and storage tanks or for minimum water temperature testing in all tanks. These omissions were confirmed during an interview with the Maintenance Director, who acknowledged the absence of documentation for water or temperature testing as per the Legionella policy. Further interviews revealed that the facility had recently terminated the Maintenance Director, which contributed to the failure in maintaining a comprehensive water management program. The Nursing Home Administrator confirmed the facility's inability to implement control measures for Legionella, which is a requirement under the Department of Health and Human Services and CMS guidelines. This deficiency highlights the facility's non-compliance with federal, state, and local requirements for infection control and prevention.
Plan Of Correction
-The facility will implement an effective Water Management Program and Infection Control Program that, at a minimum, will have a system of preventing, identifying, reporting, investigating, and controlling infections and communicable diseases. -A Water Management Program will be developed based on the framework outlined in ASHRAE standards. -The Maintenance Director/Designee will be educated on the development of the Water Management Program and its implementation by the Administrator/Designee. -Water samples will be taken in-house and sent to a certified lab for testing. -Audits will be completed by the Administrator/Designee on compliance with the Water Management system. These audits will be completed weekly for 8 weeks. -The Infection Control Program will be revised so that documentation is present for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases. -The Infection Preventionist will be educated on the revised process by the Director of Nursing/Designee. -These audits will be forwarded to the monthly Quality Assurance Performance Improvement Committee for review and frequency of audits.
Failure to Provide Anonymous Grievance Options
Penalty
Summary
Kadima Rehabilitation and Nursing at Washington was found to be non-compliant with the requirements of 42 CFR Part 483, Subpart B, specifically regarding the handling of grievances. The facility failed to provide residents and visitors with the necessary means to file grievances anonymously. During the survey, it was observed that the only grievance box available was located in the front lobby, directly in front of the Nursing Home Administrator's office and within sight of the receptionist, which compromised the anonymity of the grievance process. Additionally, there were no grievance forms or boxes available on the nursing units, further limiting the residents' ability to voice concerns without fear of reprisal. Interviews with the Resident Group and the Nursing Home Administrator confirmed these findings. The Resident Group expressed that they could not file anonymous grievances due to the location of the grievance box. The Nursing Home Administrator acknowledged the lack of grievance boxes and forms on the nursing units and the absence of an opportunity for residents and visitors to file grievances anonymously. This deficiency indicates a failure to adhere to the facility's grievance policy, which is intended to support each resident's right to voice grievances without discrimination or fear.
Plan Of Correction
1. The facility will provide the opportunity for residents and visitors to file an anonymous grievance. 2. The Regional Clinical Consultant or Designee will re-educate the Nursing Home Administrator and the Social Services Director on federal regulation 0585, detailing placing grievance boxes in an area where residents and visitors can file a grievance anonymously. 3. New grievances boxes were placed in designated areas of the facility that will give residents an area to file a grievance anonymously. 4. Social Services Director or designee will educate Residents on the whereabouts of the placement of the new grievance boxes. 5. The New Grievance procedure will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review. 6. SS Director/designee will audit/monitor (using audit grid) grievance box daily for 4 weeks and manager on duty will monitor/audit daily (using audit grid) on weekends for 4 weeks. 7. Discussion/questions/concerns will be discussed at resident council. 8. The results of the audits will be forwarded to the monthly quality assurance and performance improvement committee for review and frequency of audits.
Failure to Monitor and Report Abnormal Blood Glucose Levels
Penalty
Summary
The facility failed to properly assess, document, and notify physicians of abnormal capillary blood glucose (CBG) levels for five residents. These residents, who had diagnoses including diabetes, were not monitored according to the facility's policies and physician orders. The facility's policy required documentation of CBG levels, interventions to stabilize blood glucose, and timely communication with physicians when there was a change in a resident's condition. However, the facility did not adhere to these protocols. For Resident R13, multiple instances of hyperglycemia were recorded, with CBG levels significantly above normal. Despite these readings, there was no evidence that the resident was assessed for hyperglycemia, nor was there documentation of any interventions or physician notifications. Similar failures were noted for Residents R26, R28, R29, and R46, where high or low CBG levels were recorded, but the necessary follow-up actions, including rechecking blood sugar levels and notifying physicians, were not documented. Interviews with nursing staff revealed inconsistencies in the actions taken when abnormal CBG levels were detected. Staff members described different procedures for addressing high and low blood glucose levels, indicating a lack of standardized practice. The Director of Nursing confirmed the facility's failure to notify physicians of changes in condition, document assessments or interventions, and follow physician orders for the affected residents.
Plan Of Correction
The facility will assess, document and notify the physician of increased and decreased Capillary Blood Glucose (CBG) levels for all residents. The facility cannot retroactively correct the concerns identified for residents R13, R26, R28, R29 and R46. The previous residents R13, R26, R28, R29 and R46 physicians were notified/will be notified of abnormal CBG results for any new orders. All diabetic residents' orders will be reviewed to ensure accuracy/need for physician notification. The facility will complete a two-week look back of diabetic residents to validate the physician was notified of increased or decreased CBG, and the resident was assessed for hypoglycemia and documented. The Director of Nursing or designee will re-educate licensed nurses on the facility policy and procedures for notifying the physician with resident change in condition, detailing notification of increased or decreased CBG. The Director of Nursing or designee will complete an audit three times a week for four weeks, then monthly for three months to validate physicians are notified of any increased or decreased blood sugars and residents are assessed for hypoglycemia. The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.
Failure to Conduct Smoking Safety Assessments
Penalty
Summary
The facility failed to assess three residents for safe smoking practices, as required by their own policy. The policy mandates that smokers be reviewed on admission, at least quarterly, and as necessary depending on individual circumstances and changes in the resident's condition. However, the facility did not adhere to this policy for Residents R4, R10, and R54. Resident R4, who has a history of atrial fibrillation, seizures, and cognitive communication deficit, was last assessed for smoking safety on 12/22/23, despite the care plan indicating a need for regular reviews. Resident R10, with diagnoses of diabetes, asthma, and heart failure, was last assessed on 7/2/24, and Resident R54, with diabetes and high blood pressure, was last assessed on 8/20/24. The Director of Nursing confirmed during an interview that no further assessments were completed for these residents as required. The failure to conduct these assessments is a violation of the facility's smoking policy and the regulatory requirement to ensure the resident environment remains as free of accident hazards as possible. This oversight could potentially expose residents to risks associated with smoking, given their medical conditions and the lack of updated safety assessments.
Plan Of Correction
The facility will ensure residents are assessed for safe smoking. A smoking assessment will be completed for residents R4, R10, and R54 to ensure it is current and the resident is safe to smoke. A house audit will be completed to validate residents who smoke have a current smoking assessment completed. The Director of Nursing or Designee will re-educate licensed nurses, including new hires and agency, on the facility policy and procedures for Smoking, detailing completing safe smoking assessments for residents who wish to smoke. The Director of Nursing or Designee will complete an audit weekly for four weeks, then monthly for three months, to validate residents who smoke have a current and accurate smoking assessment. The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.
Failure to Conduct Pre-Employment Background Checks
Penalty
Summary
The facility failed to ensure the protection of residents from potential abuse by not performing criminal history background checks prior to hiring two employees. The facility's policy mandates that a criminal background check must be submitted to the Pennsylvania State Police before the start of active employment, and applicants cannot be hired or attend orientation until the background clearance is completed. However, the personnel files for a Dietary Aide and a Registered Nurse revealed no evidence of completed background checks before their respective hire dates. During an interview, a Human Resources employee confirmed the oversight, mistakenly believing that the facility had 30 days post-hire to conduct these checks. The employee also mentioned that the facility hesitated to conduct background checks immediately due to concerns about new hires not reporting to work, which would result in wasted resources. This failure to adhere to the established policy potentially exposed residents to individuals who had not been properly vetted for past abuse, neglect, or mistreatment.
Plan Of Correction
1. The facility will ensure that residents are protected from potential abuse by performing criminal history background checks prior to hire for all personnel. The facility cannot retroactively correct the concerns identified with Employees E7 and E12. 2. The Nursing Home Administrator or Designee will re-educate the Human Resources Director on federal regulation 0606, detailing completing criminal background checks prior to hire on all personnel. 3. Criminal history background check audits will be completed weekly for 4 weeks, then monthly for three months to validate criminal background checks are completed prior to hire for all new employees. 4. Criminal background checks were completed for E7 and E12. An audit will be completed on all current staff to ensure criminal background checks were completed. 5. These audits will be forwarded to the monthly Quality Assurance Performance Improvement Committee for review and frequency of audits.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility failed to ensure that residents are free of significant medication errors, as evidenced by an incident involving a resident with diabetes and high blood pressure. The resident was admitted to the facility with a physician's order to receive 12 units of Lantus insulin via a Solostar prefilled pen each morning. During a medication administration observation, an LPN set the insulin pen to the correct dose but neglected to perform the required priming procedure before administering the insulin. This priming step, as outlined in the manufacturer's guidelines, involves selecting a dose of two units, tapping the reservoir to remove air bubbles, and ensuring insulin comes out of the needle tip before administering the full dose. The LPN confirmed during an interview that she failed to prime the insulin pen prior to administering the medication to the resident. The Director of Nursing also confirmed that the facility did not administer the correct dose of insulin due to this oversight. This incident highlights a deviation from the facility's medication administration policy, which mandates that medications be administered safely, accurately, and in a timely manner, in accordance with good nursing principles and practices.
Plan Of Correction
The facility will ensure residents are free of significant medication errors. The facility cannot retroactively correct the concern identified for resident R3. The Director of Nursing or designee will re-educate licensed nurses on the facility policy and procedures for medication administration, detailing priming the insulin pen prior to administering medications. The Director of Nursing or designee will complete 5 nurse medication administration competencies weekly for four weeks, then monthly for three months to ensure insulin pens are primed prior to medication administration and residents are free from significant medication errors. The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.
Nurse Aide Staffing Deficiency
Penalty
Summary
The facility failed to meet the required nurse aide staffing levels as per the regulation effective July 1, 2024. Specifically, the facility did not provide the minimum number of nurse aides per residents during various shifts over a 21-day period. During the day shift, the facility was short of the required nurse aides on 12 out of 21 days. The evening shift experienced shortages on 14 out of 21 days, and the night shift was understaffed on 19 out of 21 days. The census data and nursing time schedules revealed that the facility consistently failed to meet the required nurse aide-to-resident ratios, with no additional higher-level staff available to compensate for these deficiencies. The Director of Nursing confirmed these staffing shortages during an interview, acknowledging the facility's failure to provide the mandated nurse aide coverage. The report details specific dates and census numbers, highlighting the discrepancies between the required and actual number of nurse aides present during each shift. This consistent understaffing indicates a systemic issue in maintaining adequate staffing levels to meet regulatory requirements.
Plan Of Correction
1. The facility cannot correct that a minimum of one nurse aide (NA) per 10 residents during the day shift for 12 of 21 days (12/29 and 12/31/2024, 1/3, 1/4/25, 1/5, 1/6, 1/7, 1/10, 1/11, 1/12, 1/14, and 1/16/25), one NA per 11 residents during the evening shift for 14 of 21 days (12/31/2024, 1/3, 1/4/25, 1/5, 1/6, 1/7, 1/8, 1/9, 1/10, 1/11, 1/12, 1/13, 1/16, and 1/18 25) and one NA per 15 residents during the night shift for 19 of 21 days (12/29 and 12/30, 12/31/24, 1/1, 1/2/25, 1/3, 1/4/25, 1/5, 1/6, 1/7, 1/8, 1/9, 1/10, 1/11, 1/12, 1/13, 1/14, 1/17, and 1/18/25). 2. The facility will ensure that nurse aide staffing ratios are met every shift. 3. The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5520 and ensuring nurse aide staffing ratios are met each shift. Daily shift staffing ratios will be reviewed at daily staffing meetings. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects to not meet staffing ratios on a given shift, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist. 4. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure nurse aide staffing ratios are being met. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.
LPN Staffing Deficiencies
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) across various shifts over a 21-day period. Specifically, the facility did not provide the minimum number of LPNs per resident during the day, evening, and night shifts on multiple occasions. For the day shift, the facility was short of the required LPNs on 13 out of 21 days, with the census ranging from 62 to 65 residents, necessitating between 2.48 to 2.60 LPNs. However, the facility only provided between 2.00 to 2.13 LPNs, with no additional higher-level staff available to compensate for the deficiency. Similarly, during the evening shift, the facility was understaffed on 7 out of 21 days, with the census requiring between 2.07 to 2.17 LPNs, but only 1.56 to 2.00 LPNs were provided. The night shift also experienced staffing shortages on 13 out of 21 days, with the census requiring between 1.55 to 1.60 LPNs, but only 0.25 to 1.25 LPNs were available. These staffing deficiencies were identified through a review of the facility's census data, nursing time schedules, and deployment sheets, indicating a consistent failure to meet the regulatory requirements for LPN staffing levels during the specified period.
Plan Of Correction
1. The facility cannot correct that the facility administrative staff failed to provide a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift for 13 of 21 days (12/29/24, 1/3, 1/4/25, 1/5, 1/7, 1/8, 1/9, 1/12, 1/13, 1/14, 1/15, 1/16, and 1/18/25), one LPN per 30 residents on the evening shift for 7 of 21 days (12/30/24, 1/5, 1/6, 1/12, 1/14, 1/16, and 1/18/25) and one LPN per 40 residents on the night shift for 13 of 21 days (12/29, 12/30, and 12/31/24, 1/1, 1/2/25, 1/5, 1/6, 1/9, 1/10, 1/11, 1/14, 1/16, and 1/18/25). 2. The facility will ensure that LPN staffing ratios are met every shift. 3. The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5530 and ensuring LPN staffing ratios are met each shift. Daily shift staffing ratios will be reviewed at daily staffing meetings. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects to not meet staffing ratios on a given shift, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist. 4. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure LPN staffing ratios are being met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.
Staffing and Care Hours Deficiency
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) during various shifts, as confirmed by the Director of Nursing (DON) during an interview. Specifically, the facility did not provide the minimum number of LPNs per residents during the day, evening, and night shifts. Additionally, the facility did not meet the mandated 3.2 hours of direct resident care per resident in a 24-hour period on 17 out of 21 days, as evidenced by a review of nursing schedules and census information. The Patient Per Day (PPD) hours fell below the required threshold on multiple dates, with the lowest being 2.21 hours on one occasion. These deficiencies were acknowledged by the DON, indicating a consistent shortfall in providing adequate nursing care over the specified period.
Plan Of Correction
1. The facility cannot correct that the minimum number of general nursing hours to each resident in a 24-hour period were not met on 17 of 21 days (12/29, 12/30, and 12/31/24, 1/1, 1/3, 1/4/25, 1/5, 1/6, 1/7, 1/8, 1/9, 1/10, 1/11, 1/12, 1/14, 1/16, and 1/18/25). 2. The facility will ensure that general nursing hours are met every shift. 3. The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5640 and ensuring general nursing hours to each resident are met each shift. Daily shift staffing hours will be reviewed at daily staffing meetings. The Nursing Supervisors will review shift staffing on the weekends. If the facility projects to not meet general nursing hours to each resident on a given shift, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist. 4. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure general nursing hours for each resident are being met. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident identified as being at risk. The resident, who was cognitively impaired with a BIMS score of 7, indicating severe impairment, had a history of exit-seeking behavior and was documented to have attempted to leave the facility on previous occasions. Despite these known risks, the resident was able to leave the facility unsupervised and was found sitting in the grass outside the building by staff members who were retrieving personal food deliveries. The incident occurred when two nurse aides noticed the resident outside after exiting the building for personal reasons. The resident claimed to have pressed buttons to open the door, although the door was reported to be functioning correctly and required a password to open. Staff interviews confirmed that the resident frequently exhibited exit-seeking behavior, and the Nursing Home Administrator acknowledged the failure to provide adequate supervision. The facility's policies and procedures for monitoring residents at risk for elopement were not effectively implemented, leading to this deficiency.
Deficiency in Staff Training on Elopement Risks
Penalty
Summary
The facility failed to provide documentation of an effective training program tailored to the needs of its resident population, specifically for one resident identified as Resident R1. The facility's policy on staff development mandates that employees must be competent in skills necessary to care for residents' needs, with an ongoing education program addressing residents' problems, needs, and rights. However, the facility did not demonstrate that such a program was effectively implemented, as evidenced by the incident involving Resident R1, who was at risk for elopement due to cognitive impairment and exit-seeking behaviors. Resident R1, who had a BIMS score indicating severe cognitive impairment, was found outside the facility after reportedly pressing buttons to open a door or being let out by another person. Despite being care planned as an elopement risk, the facility's training did not address the specific method used by the resident to exit the building. Interviews with staff and the Nursing Home Administrator confirmed that while education was provided on identifying and care planning for residents at risk of wandering and elopement, it did not cover the actual circumstances of Resident R1's elopement.
Failure to Secure Residents' Medical Records
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical information by improperly storing approximately 75 boxes of loose paper containing resident information in an unsecured storage shed behind the facility. This action was in direct violation of the facility's policy on confidentiality, which mandates that residents have the right to personal privacy and confidentiality of their personal and clinical records. Additionally, the facility's policy on medical records storage requires that all medical records be stored in a secure, fire-protected, and waterproof area. During an observation, it was noted that the storage shed was left unsecured at all times, compromising the confidentiality of the residents' information. The Maintenance Director confirmed that the paperwork was stored in the shed due to a lack of space. The Nursing Home Administrator acknowledged the failure to maintain the confidentiality and security of the residents' medical information in the storage shed.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in the North Wing Nursing Unit and the main dining room. Observations revealed several deficiencies: two residents had a hole in the floor near the bathroom baseboard, two residents had chipped paint under the window surrounding the heater, and two residents had a cracked ceiling above a bed, with one resident expressing concern about potential leaks. An empty resident room had a broken wall plug plate in the bathroom, and another resident's room had unfinished drywall with spackling behind the beds. Additionally, the main dining room floor was observed to have multiple spots of a brown substance and appeared soiled with food debris. These findings were confirmed by the Nursing Home Administrator and the Maintenance Director during an interview.
Neglect Due to Non-Compliance with Transfer Guidelines
Penalty
Summary
The facility failed to protect a resident from neglect by not following physician's orders during incontinence pad and linen changes. Specifically, a nurse aide (NA) rolled a resident onto her right side, where there was no enabler bar, causing the resident to fall onto the floor. The resident, who required assistance from two staff members for bed mobility, had expressed discomfort with being rolled without a second person present. Despite this, the NA proceeded, resulting in the resident's fall. The resident involved had a medical history that included diabetes, a history of pulmonary blood clots, bacteremia, and a wound on her right leg. The incident occurred during a routine care procedure, highlighting a lapse in adherence to the prescribed care plan, which required two staff members for safe bed mobility. The failure to follow these guidelines directly led to the resident's fall and constituted neglect as defined by the facility's policies and federal regulations.
Inadequate Supervision and Bed Mobility Intervention
Penalty
Summary
The facility failed to provide adequate supervision and implement effective bed mobility interventions for a resident, identified as Resident R8, as per physician orders. Resident R8, who had a history of diabetes, pulmonary blood clots, bacteremia, and a wound on her right leg, required assistance from two staff members for bed mobility. However, during an incident, a nurse aide, identified as Employee E2, attempted to provide incontinence care and linen change alone, rolling Resident R8 onto her right side where there was no enabler bar, resulting in the resident falling onto the floor. This incident occurred despite Resident R8 expressing discomfort with being rolled without a second person present. Interviews with staff revealed inconsistencies in how they accessed and understood the required level of assistance for residents. While some staff referred to a kiosk for information, others relied on clinical records. The Nursing Home Administrator confirmed the facility's failure to provide adequate supervision for Resident R8, which was a violation of the facility's policy on accidents and incidents. The deficiency was identified as past non-compliance, indicating that the facility had not adhered to the required standards of care and supervision at the time of the incident.
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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 Washington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Transitions Healthcare Washington Pa | 1.8 mi | ★★★★★ | 13 | 0 |
| Premier Washington Rehabilitation And Nursing Ctr | 2.4 mi | ★★★★★ | 17 | 0 |
| Southmont Of Presbyterian Seniorcare | 3.1 mi | ★★★★★ | 9 | 0 |
| Greenery Center For Rehab And Nursing | 6.3 mi | ★★★★★ | 45 | 1 |
| Townview Health And Rehabilitation Center | 6.9 mi | ★★★★★ | 4 | 0 |
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