Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Transitions Healthcare Washington Pa during CMS and state inspections, most recent first.
The facility failed to ensure call lights were answered timely for multiple residents. Residents with BIMS scores ranging from cognitively intact to moderately impaired reported waiting 30 minutes or more, sometimes over an hour, for help, including assistance with toileting and changing soiled briefs. Several residents said staff would turn off the call light and leave without providing the requested care, and some noted the delays happened more often with agency staff. The DON confirmed the issue.
Posted appointment notices with a resident’s medical information were observed in the resident’s room, including on a corkboard visible from the doorway and taped beside the bed. The notices listed specialist appointments with dates, times, and addresses, and the care plan did not show permission for the postings. An LPN confirmed the notices were visible to others, and the DON confirmed the confidentiality failure.
Inaccessible Grievance Boxes on Two Nursing Units: The facility failed to make grievance boxes accessible on the skilled care and intermediate care units. A grievance policy stated residents could file grievances anonymously by placing forms in a grievance box, but during observation the skilled care unit box was 70 inches high and the intermediate care unit box was 49.5 inches high, making both inaccessible to many residents, including those using wheelchairs. The DON confirmed the issue.
Failure to Maintain Oxygen Equipment and Respiratory Care: Four residents receiving ordered oxygen therapy were observed with oxygen tubing that was unlabeled, illegible, or dated inconsistently with facility policy. Two residents also lacked care plans for oxygen use. The residents had diagnoses including acute respiratory failure, respiratory failure, COPD, hypertension, diabetes mellitus, and anxiety disorder, and the DON confirmed the facility failed to provide appropriate respiratory care and maintain oxygen equipment.
A resident with ESRD, CVA, and dependence on renal dialysis had a dialysis schedule of three treatments per week at a dialysis center, but the facility did not maintain consistent dialysis communication. The dialysis communication forms were repeatedly left incomplete because the dialysis nurse and nursing home nurse did not sign multiple entries, and the DON confirmed the communication process was not consistently maintained.
A resident assessed as able to smoke independently was observed smoking outside the front entrance instead of only in the designated smoking area. The resident kept cigarettes and a lighter in his room or on his person, despite signing the smoking policy and acknowledging that smoking items were not to be stored in his room. The DON confirmed the facility did not enforce its smoking policy, smoking areas, or smoking safety requirements.
The facility failed to carry out its COVID-19 vaccination program as outlined in its infection control policy by not administering the vaccine to multiple residents after obtaining consent. Residents and/or their responsible parties were educated about the COVID-19 vaccine and signed consent forms, including newly admitted residents, but review of electronic MARs showed that the vaccine was not administered as consented. The DON confirmed that dozens of residents who had consented to vaccination had not received the COVID-19 vaccine.
A resident with significant mobility and medical needs, including a requirement for mechanical lift transfers with two staff, was transferred by a single nursing assistant without proper equipment. During the transfer, the resident sustained a 5 cm laceration to the shin after striking the wheelchair, requiring sutures. The nursing assistant was unaware of the resident's transfer requirements, leading to inadequate supervision and actual harm.
A resident with locked-in state was observed with bruising and pain on the right thumb, but nursing progress notes did not include documentation of an evaluation for these findings. The DON confirmed the lack of required documentation, resulting in incomplete clinical records.
A resident received medications publicly in the dining hall, contrary to the facility's policy for private administration. Additionally, two residents expressed fear of retaliation when voicing grievances, with one feeling discriminated against and another fearing neglect. The facility's administration confirmed these failures.
A facility failed to ensure a resident's drug regimen was free from unnecessary psychotropic medications without adequate indications for use. The resident received multiple antidepressants without a documented depression diagnosis in the MDS assessment. The Nursing Home Administrator and DON confirmed the oversight, indicating a failure to adhere to the facility's policy and relevant regulations.
The facility failed to maintain smoke barrier doors in compliance with NFPA 101 standards, affecting two smoke compartments. An observation revealed an excessive gap between the meeting edges of the doors leading to rooms 100-132, compromising their ability to resist smoke passage. This was confirmed by interviews with facility staff.
The facility was found to have mixed standard response and quick response sprinkler heads in the basement hallway, failing to meet automatic sprinkler system installation requirements. This was confirmed through observation and interviews with facility staff.
The facility failed to maintain the automatic sprinkler system, with deficiencies found in the Electrical Room/Maintenance Office and the laundry room. A large gap in the ceiling tile above an electrical panel and a missing escutcheon plate on a sprinkler head were observed. These issues were confirmed by the Facility Administrator, Maintenance Personnel, and the Plant Operations Director.
The facility failed to maintain corridor doors according to NFPA 101 standards, as four doors did not close and latch properly during an inspection. This deficiency was confirmed through interviews with facility staff.
The facility failed to maintain battery-operated carbon monoxide alarms according to the 2016 Act 48-Care Facility Carbon Monoxide Alarms Standards Act. It was observed that the facility did not have an Evacuation and Alarm Protocols policy for the carbon monoxide detectors/alarms. This deficiency was confirmed in an interview with the Facility Administrator, Maintenance Personnel, and the Plant Operations Director, impacting the entire facility.
The facility did not ensure smoke dampers were inspected every four years as required by NFPA 105. Documentation review revealed the absence of inspection records, and interviews with facility staff confirmed the lack of available documentation.
The facility failed to maintain and inspect the emergency generator, affecting the entire facility. Documentation for weekly inspections of battery electrolyte levels or voltage and monthly electrolyte specific gravity or conductance testing was missing. Interviews confirmed the lack of documentation, indicating non-compliance with NFPA standards.
Transitions Healthcare Washington PA failed to secure a medication cart, leaving it unlocked and unattended with various medications and medical supplies on top. The facility's policy requires that medication carts be locked when not attended by authorized personnel. Staff interviews confirmed the lapse in securing the cart and its contents, violating federal and state regulations.
A resident with severe cognitive impairment was physically abused by a nurse aide, who was witnessed striking the resident multiple times. The incident resulted in a visible injury, and the resident's care plan for managing agitation was not followed. The facility failed to protect the resident from abuse.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to ensure call lights were answered timely for 14 of 20 residents reviewed, including residents with varying cognitive status and multiple complaints about delayed response. Facility policy stated staff should respond immediately when answering a call light from the nurse's station. The report identified residents with BIMS scores ranging from 9 to 15, including cognitively intact and moderately impaired residents, and documented repeated grievances and interviews describing long waits for assistance, often 30 minutes or more and sometimes over an hour. Resident complaints included call lights being turned off by staff who said they would return soon but did not, residents remaining in soiled briefs, and delays when needing help to the bathroom or with care. Several residents reported this occurred often, and some stated it happened more frequently with agency staff. The DON confirmed during interview that the facility failed to make certain call lights were answered timely.
Posted appointment notices exposed resident PHI
Penalty
Summary
The facility failed to maintain the confidentiality of a resident’s medical information for Resident R88. Facility policy on safeguarding posted protected health information stated that the facility would protect the privacy of residents’ PHI from intentional or unintentional view when posting information, including information at the bedside, on whiteboards, on walls, or in other public spaces. Resident R88 was admitted with diagnoses including diabetes, history of falling, and muscle weakness, and the MDS dated 3/10/26 showed those diagnoses remained current. During an observation on 3/23/26, two doctor appointment notice sheets were seen posted in the resident’s room on bright green paper: one on the corkboard visible from the doorway and another taped beside the bed. The notices listed a vascular appointment and a nephrology appointment, including dates, times, and addresses. The care plan initiated 7/9/25 did not indicate that Resident R88 had given permission for the signs to be posted where they were visible to other residents, visitors, family, and non-medical staff. An LPN confirmed the notices were posted in view of others, and the DON confirmed the facility failed to maintain confidentiality of the resident’s medical information.
Inaccessible Grievance Boxes on Two Nursing Units
Penalty
Summary
The facility failed to make grievance boxes accessible to residents on two of three nursing unit locations, including the skilled care unit and the intermediate care unit. The facility policy, dated 1/6/26 with a previous review date of 1/6/25, stated that grievances may be filed anonymously by placing a completed form in a grievance box and that methods for reporting concerns and grievances would be posted and accessible to residents and resident representatives. During an observation and interview on 3/24/26 at 11:00 a.m., Employee E3 and the surveyor measured the grievance boxes on the skilled care unit and the intermediate care unit. The skilled care unit grievance box was 70 inches above the floor and in line of sight of the nurse's station, out of reach of most ambulatory residents and all residents using wheelchairs. The intermediate care unit grievance box was 49.5 inches above the floor, out of reach of residents in wheelchairs. During an interview on 3/24/25 at 2:00 p.m., the DON confirmed the facility failed to make accessible grievance boxes to all residents.
Failure to Maintain Oxygen Equipment and Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care and maintain oxygen equipment for four residents who were receiving ordered oxygen therapy. Facility policy for oxygen concentrators, reviewed on 1/6/26, indicated that cannulas were to be changed weekly and as needed. Resident R15 had diagnoses including acute respiratory failure, hypertension, and anxiety disorder, and was ordered 2 liters per minute of oxygen. During an observation on 3/22/26, R15 was seen using oxygen, but the oxygen tubing was not labeled, and the clinical record did not contain a care plan for oxygen use. Resident R22 had diagnoses including respiratory failure, diabetes mellitus, and hypertension, and was ordered 2 liters per minute of oxygen. During an observation on 3/20/26, R22 was seen using oxygen, but the oxygen tubing date label was illegible, and the clinical record did not contain a care plan for oxygen use. Resident R70, with diagnoses including acute respiratory failure, hypertension, and anxiety disorder, was ordered 5-7 liters per minute of oxygen; during an observation on 3/22/26, the oxygen tubing date label was illegible. Resident R77, with diagnoses including COPD, diabetes mellitus, and anxiety disorder, was ordered 3 liters per minute of oxygen; during an observation on 3/22/26, the oxygen tubing was dated 3-12-26. The DON confirmed on 3/22/26 that the facility failed to provide appropriate respiratory care and maintain oxygen equipment.
Incomplete Dialysis Communication for Resident on Scheduled Hemodialysis
Penalty
Summary
The facility failed to maintain consistent dialysis communication for Resident R16, who had diagnoses of end stage renal disease, cerebrovascular accident, and dependence on renal dialysis. The resident’s physician order directed dialysis three times weekly at the dialysis center with an 8:00 a.m. chair time, and the care plan reflected dialysis on Tuesday, Thursday, and Saturday, although it also still listed an original discontinued schedule of Monday, Wednesday, and Friday. Review of the dialysis communication forms from 1/1/26 through 3/22/26 showed multiple incomplete entries. The dialysis nurse and nursing home nurse did not sign forms on 3/10, 3/17, and 3/21; the nursing home nurse did not sign on 2/14, 2/24, 2/28, and 3/7; and the dialysis nurse did not sign on 1/3, 1/10, 1/13, 1/17, 1/20, 1/24, 1/27, 1/31, 2/5, 2/7, 2/10, 2/17, and 3/3. The facility policy stated that each resident is provided a dialysis communication binder so the facility and dialysis center can communicate, and the DON confirmed in interview that the facility failed to make certain consistent dialysis communication was maintained.
Failure to Enforce Smoking Policy and Smoking Safety
Penalty
Summary
The facility failed to enforce its established smoking policy and smoking safety requirements for one resident who was assessed as able to smoke independently. The resident had diagnoses of diabetes mellitus, hypertension, and hyperlipidemia. Facility policy stated that smoking was only permitted in the designated external courtyard area by the courtyard cafe, that smoking paraphernalia had to be kept secure by the facility, and that if staff learned a resident had smoked in an unauthorized area or possessed smoking paraphernalia, the resident would be asked to turn the items over and allow a room search. Although the resident signed an acknowledgement of the smoking policy and a smoking/tobacco/vaping safety assessment indicated he understood that smoking items were not to be stored in his room, surveyors observed him smoking outside the front entrance of the building and later again at the front entrance. During an interview and observation, the resident stated he kept his cigarettes and lighter in his room or on his person, and the cigarettes and lighter were observed in his room. He also stated he could smoke in three locations at the facility, including the front entry, the courtyard, and the back parking lot. During rounds with the DON, the resident confirmed he kept his cigarettes and lighter with him in his room and was not giving them up to anyone, and that he smoked outside the front lobby or the courtyard. The DON confirmed the facility failed to enforce its smoking policy, smoking areas, and smoking safety.
Failure to Administer COVID-19 Vaccine After Obtaining Resident Consent
Penalty
Summary
The facility failed to implement its COVID-19 vaccination program in a timely manner for multiple residents after obtaining consent for vaccination. Facility policy titled "Infection Control - Covid 19 Care and Management Policy, Section Vaccinations" dated 1/6/26 stated that residents are encouraged to remain up to date with all recommended COVID-19 vaccine doses and that newly admitted residents’ vaccination status is to be determined and a vaccine offered as recommended. Review of resident education and consent documents showed that residents and/or their responsible parties were educated about the COVID-19 vaccine and consent forms were completed on 9/29/25, 9/30/25, and upon admission during the period of 12/22/25 through 1/7/26. During this timeframe, 48 resident consent forms were completed for administration of the vaccine. However, review of the electronic medication administration records revealed that the facility did not administer the COVID-19 vaccine at the time the consent forms were completed, and the vaccinations were not provided as consented. This failure affected 30 of 105 residents on 9/29/25, five of 108 residents on 9/30/25, 10 residents admitted between 12/22/25 and 1/7/26, and three residents whose consent forms were undated. During an interview on 1/28/26 at 12:15 p.m., the DON confirmed that as of that date, the facility had failed to provide 48 residents the COVID-19 vaccine despite having obtained consent from the residents or their responsible parties, in violation of 28 Pa Code: 201.18(b)(1) Management.
Failure to Follow Transfer Protocols Resulting in Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision and follow established transfer protocols, resulting in actual harm to a resident. The resident, who had diagnoses including anxiety, spinal stenosis, muscle weakness, and syncope, required substantial/maximal assistance for transfers and had a physician order and care plan specifying transfer with a mechanical lift and the assistance of two staff members. Despite these documented requirements, the resident was transferred from bed to wheelchair by a single nursing assistant without the use of a mechanical lift. During this transfer, the resident's left shin struck the wheelchair leg rest, causing a 5 cm laceration that required hospital treatment and sutures. The nursing assistant involved stated that the transfer was performed alone because the resident indicated that one person could assist her, and the assistant was unaware of the resident's need for a mechanical lift. Review of facility policies and the resident's care plan confirmed that the transfer should have been performed with two staff and a mechanical lift. The incident was identified as past non-compliance, and interviews with staff and facility leadership confirmed the failure to provide adequate supervision and adherence to transfer protocols, resulting in injury.
Incomplete Documentation of Resident Medical Records
Penalty
Summary
The facility failed to ensure that medical records for a resident were complete and accurately documented. Specifically, a resident with a diagnosis of locked-in state was admitted with ongoing complex care needs. An incident report noted that the resident was observed with bruising and a complaint of pain on the right thumb. However, a review of the resident's nurse progress notes revealed there was no documentation of an evaluation for the bruising and pain. The Director of Nursing confirmed that the required documentation was missing, indicating that the facility did not maintain complete clinical records as required by policy and regulation.
Failure to Uphold Resident Privacy and Address Grievances
Penalty
Summary
The facility failed to uphold the privacy and dignity of a resident, identified as R77, during medication administration. Despite the facility's policy requiring medications to be administered in private, R77 was observed receiving both pills and liquid medications in the dining hall while awaiting a Resident Group meeting. This was confirmed by both a Licensed Practical Nurse and a Registered Nurse, who acknowledged that there was no order or care plan allowing for medication administration outside of the resident's room. Additionally, the facility did not ensure that residents could voice grievances without fear of retaliation. Three residents expressed concerns about potential retaliation when voicing complaints. One resident felt discriminated against and feared not receiving assistance or being able to arrange transportation for an event. Another resident was hesitant to be interviewed until assured of anonymity, fearing that speaking up would lead to neglect or mistreatment by staff. The Nursing Home Administrator and Director of Nursing confirmed these failures in upholding resident rights.
Failure to Ensure Appropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically psychotropic drugs, without adequate indications for use. The facility's policy on the Behavioral Health Program mandates that psychotropic medications should only be used when necessary to treat a specific diagnosed and documented condition. However, a review of Resident R50's records revealed that the resident was receiving multiple antidepressant medications, including Mirtazapine, Trazodone, and Duloxetine, without a documented diagnosis of depression in the Minimum Data Set (MDS) assessment. This indicates a lack of adherence to the facility's policy regarding the use of psychotropic medications. During an interview, the Nursing Home Administrator and the Director of Nursing confirmed the oversight in ensuring that the resident's drug regimen was free from unnecessary medications. The deficiency was identified for one of five residents reviewed, highlighting a failure in the facility's processes to adequately document and justify the use of psychotropic medications. The report cites specific Pennsylvania Code regulations related to the responsibility of the licensee, physician services, pharmacy services, and nursing services, which were not adhered to in this instance.
Smoke Barrier Door Deficiency
Penalty
Summary
The facility failed to maintain smoke barrier doors in compliance with NFPA 101 standards, specifically affecting two of nine smoke compartments. During an observation on March 19, 2025, at 11:40 a.m., it was noted that the smoke barrier doors leading to rooms 100-132 (ICF-1) had an excessive gap between the meeting edges. This gap compromised the doors' ability to resist the passage of smoke, which is a critical safety requirement. An interview conducted with the Facility Administrator, Maintenance Personnel, and the Plant Operations Director at 12:30 p.m. on the same day confirmed the presence of the excessive gap. This deficiency indicates a failure to ensure that the smoke barrier doors met the necessary standards to prevent smoke passage, as required by the 2012 NFPA 101 code for existing buildings.
Plan Of Correction
1. The smoke door on ICF 1 is being evaluated by the vendor for repair or replacement if indicated. 2. No other smoke doors were identified with gaps. 3. The Director of Plant operations or designee will audit smoke barrier doors monthly x 3 months. 4. Audits will be taken to the safety committee and submitted to the QAPI committee for review of findings and further interventions are warranted.
Sprinkler System Installation Deficiency
Penalty
Summary
The facility failed to maintain automatic sprinkler system installation requirements as evidenced by the presence of mixed standard response and quick response sprinkler heads in the basement hallway. This deficiency was identified during an observation conducted on March 19, 2025, between 10:35 a.m. and 10:55 a.m. The issue was confirmed through an interview with the Facility Administrator, Maintenance Personnel, and the Plant Operations Director on the same day at 12:30 p.m.
Plan Of Correction
1. Sprinkler heads were converted so that all sprinkler heads were standardized to the quick response sprinkler head. 2. No other variant sprinkler heads were identified within the facility. 3. The Director of Plant operations or designee will audit sprinkler heads to ensure that they are all the quick response sprinkler heads monthly x 3 months. 4. Audits will be taken to the safety committee and submitted to the QAPI committee for review of findings and further interventions are warranted.
Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain the automatic sprinkler system in two instances during an inspection of over 30 rooms. The first deficiency was observed in the Electrical Room/Maintenance Office, where a large gap in the ceiling tile above an electrical panel was noted. This gap could potentially allow the passage of heat and smoke, which may affect the operation of the automatic sprinkler system. The second deficiency was identified in the laundry room, where a sprinkler head was missing an escutcheon plate near the washing machines. These deficiencies were confirmed during an interview with the Facility Administrator, Maintenance Personnel, and the Plant Operations Director.
Plan Of Correction
1. The ceiling tile in the electrical/maintenance office was replaced so no gap exists. The escutcheon plate was replaced in the laundry room. 2. No further ceiling tiles were identified that had a gap. No other escutcheon plates were identified as missing. 3. The Director of Plant operations or designee will audit ceiling tiles and escutcheon plates monthly x 3 months. Audits will be taken to the safety committee and submitted to the QAPI committee for review of findings and further interventions are warranted.
Failure to Maintain Corridor Doors
Penalty
Summary
The facility failed to maintain corridor doors in compliance with NFPA 101 standards, as evidenced by observations made during a survey. Specifically, four out of more than 40 corridor doors inspected did not close and latch properly. This deficiency was identified during an inspection on March 19, 2025, when surveyors observed that the doors to resident rooms 124, 125, and 134 did not close and latch when tested. The deficiency was confirmed through an interview with the Facility Administrator, Maintenance Personnel, and the Plant Operations Director on the same day. The report highlights that the corridor doors are required to resist the passage of smoke and have positive latching hardware, which was not met in these instances. The failure to maintain these doors could potentially compromise the safety standards set for the facility.
Plan Of Correction
1. The doors of room 124, 125 and 134 had the hinges tightened and the transitions trips have been exchanged to ensure an easy closure of the door. 2. No other doors were identified as not latching. 3. The Director of Plant operations or designee will audit the latching of doors monthly x 3 months. 4. Audits will be taken to the safety committee and submitted to the QAPI committee for review of findings and further interventions are warranted.
Failure to Implement Carbon Monoxide Alarm Protocols
Penalty
Summary
The facility was found deficient in maintaining battery-operated carbon monoxide alarms as per the 2016 Act 48-Care Facility Carbon Monoxide Alarms Standards Act. During an observation on March 19, 2025, it was noted that the facility had not developed or implemented an Evacuation and Alarm Protocols policy for the carbon monoxide detectors/alarms. This deficiency was confirmed in an interview with the Facility Administrator, Maintenance Personnel, and the Plant Operations Director, indicating a failure to comply with the required safety standards, affecting the entire facility.
Plan Of Correction
1. The facility has a Carbon Monoxide Evacuation and alarm policy that has been effective since 6/1/2018. 2. The Director of Operations provided education to the Nursing Home Administrator and Director of Plant Operations as to the location of this policy. 3. The policy will be reviewed by the Safety committee and a carbon monoxide alarm drill will be conducted. 4. Additionally, the policy was taken to QAPI for review and placed in the emergency preparedness binder.
Failure to Inspect Smoke Dampers Within Required Period
Penalty
Summary
The facility failed to ensure that smoke dampers were inspected within the required four-year period, as mandated by NFPA 105, Standard for the Installation of Smoke Door Assemblies and Other Opening Protectives. During a documentation review on March 19, 2025, it was discovered that the facility lacked the necessary documentation to confirm that these inspections had been conducted. An interview with the Facility Administrator, Maintenance Personnel, and the Plant Operations Director further confirmed that the smoke damper inspection documentation was not available at the time of the survey.
Plan Of Correction
1. The damper inspection was completed on 2/27/2025 and a copy of the inspection was obtained from the vendor and is maintained at the facility. 3 motors were installed 3/10/24 and all dampers had passed inspection. 2. Education was completed by the NHA to the Director of Plant Operations on keeping documents in an orderly binder. 3. The document was placed in the life safety binder. 4. TELS was updated to reflect the next 4-year scheduled inspection due date.
Failure to Maintain Emergency Generator Documentation
Penalty
Summary
The facility failed to maintain and inspect the emergency generator as required, which affected the entire facility. During a document review on March 19, 2025, it was found that the facility could not provide documentation for weekly inspections of battery electrolyte levels or battery voltage. Additionally, there was no documentation for monthly electrolyte specific gravity or conductance testing. Interviews with the Facility Administrator, Maintenance Personnel, and the Plant Operations Director confirmed the absence of the necessary documentation at the time of the survey. This lack of documentation indicates a failure to adhere to the maintenance and testing protocols outlined in NFPA 101 and related standards, which are critical for ensuring the reliability of the emergency power system.
Plan Of Correction
1. The facility generator runs on a maintenance free battery. A battery voltage testing device has been obtained. The maintenance director or designee will conduct weekly battery voltage testing and monthly conductive testing and document the findings. 2. No other generator documentation was identified as missing. 3. Education was provided to the Maintenance Director on K918 and the weekly and monthly testing has been added to the TELS system. 4. The Director of Plant operations or designee will battery voltage and conductive testing monthly x 3 months.
Medication Cart Security Lapse
Penalty
Summary
Transitions Healthcare Washington PA was found to be non-compliant with federal and state regulations regarding the labeling and storage of drugs and biologicals. During an abbreviated survey conducted in response to a complaint, it was observed that a medication cart, referred to as 'A' cart, was left unlocked and unattended. The computer screen on the cart was open to the electronic medication administration record, which should have been secured. On top of the cart, there were various medications and medical supplies, including a pair of scissors, a bottle of Miralax, 13 bottles of over-the-counter medications, six bottles of liquid prescription medication, an intravenous antibiotic solution bag, and four medication blister packs. Interviews with staff revealed a lack of adherence to the facility's policy on medication storage. A Licensed Practical Nurse (LPN) acknowledged that the bottles on the cart were over-the-counter medications, while the Assistant Director of Nursing confirmed that medication carts should be secured when unattended, and medications should be stored inside the cart. The failure to secure the medication cart and its contents was a direct violation of the facility's policy and federal regulations, which require that drugs and biologicals be stored in locked compartments and only accessible to authorized personnel.
Plan Of Correction
Preparation and or evaluation of the following plan of correction set forth in this document does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and or executed solely because it is required by the provisions of federal and state law. Immediately upon identification, all biologicals identified were secured including the scissors. The cart was locked, and the computer screen closed. The four other medication carts were checked and no other concern identified. Employee 1 was immediately provided education on the storage of biologicals policy and procedure. Education on the storage of biologicals policy and procedure has been completed with the licensed staff. On March 4, 2025, the Director of Nursing initiated visual cart inspections five days a week for four weeks. Results of audits will be taken to the next QAPI meeting on March 14, 2025, for review/discussion.
Resident Abuse Incident in LTC Facility
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving a nurse aide (NA) who was witnessed striking a resident multiple times. The resident, who had severe cognitive impairment due to dementia, was unable to defend herself or report the abuse effectively. The incident was observed by another NA, who reported that the abusive NA restrained the resident by holding her arms down and then slapped her in the face several times. This resulted in a visible abrasion on the resident's nose. The resident's care plan included strategies for managing agitation, such as allowing the resident to de-escalate and guiding her away from sources of distress. However, there were no documented behavioral symptoms in the days leading up to the incident, suggesting that the resident was not exhibiting combative behavior at the time. The facility's failure to ensure the resident's safety and adherence to the care plan contributed to the occurrence of the abuse.
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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) |
|---|---|---|---|---|
| Kadima Rehabilitation & Nursing At Washington | 1.8 mi | ★★★★★ | 29 | 0 |
| Premier Washington Rehabilitation And Nursing Ctr | 1.8 mi | ★★★★★ | 17 | 0 |
| Southmont Of Presbyterian Seniorcare | 1.9 mi | ★★★★★ | 9 | 0 |
| Greenery Center For Rehab And Nursing | 5 mi | ★★★★★ | 45 | 1 |
| Townview Health And Rehabilitation Center | 5.7 mi | ★★★★★ | 4 | 0 |
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