A list of the most recent deficiencies for Washington Odd Fellows Home. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-09-14 | 2023-10-20 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-09-14 | 2023-10-20 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-09-14 | 2023-10-20 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-09-14 | 2023-10-20 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-09-14 | 2023-10-20 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-09-14 | 2023-10-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-14 | 2023-10-20 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-09-14 | 2023-10-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-14 | 2023-10-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-14 | 2023-10-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-14 | 2023-10-20 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-09-14 | 2023-10-20 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-09-14 | 2023-10-20 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-09-14 | 2023-10-20 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-09-05 | 2023-09-28 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-09-05 | 2023-09-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-09-05 | 2023-09-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-05 | 2023-09-26 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-09-05 | 2023-09-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-09-05 | 2023-09-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-05 | 2023-09-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-05 | 2023-09-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-09-05 | 2023-09-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-05 | 2023-09-15 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-09-05 | 2023-09-06 | N |
| Meet other general requirements. | Fire Safety | 2023-09-05 | 2023-09-06 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-09-05 | 2023-09-06 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-09-05 | 2023-09-06 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-09-05 | 2023-09-06 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-07-26 | 2023-08-07 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-14 | 2023-04-03 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-02-28 | 2023-03-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-02-28 | 2023-03-28 | Y |
| Implement a program that monitors antibiotic use. | Health | 2022-11-29 | 2023-01-05 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-11-29 | 2023-01-05 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-07-27 | 2022-09-05 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-27 | 2022-09-05 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-07-27 | 2022-09-05 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-07-27 | 2022-09-05 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-07-27 | 2022-09-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-27 | 2022-09-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-27 | 2022-09-05 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-07-27 | 2022-09-05 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-07-27 | 2022-09-05 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-07-27 | 2022-09-05 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-07-27 | 2022-09-05 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-07-27 | 2022-09-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-27 | 2022-09-05 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-07-27 | 2022-09-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-27 | 2022-09-05 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-07-27 | 2022-09-05 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2022-07-27 | 2022-09-05 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-07-27 | 2022-08-23 | N |
| Report COVID19 data to residents and families. | Health | 2022-08-18 | 2022-08-19 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-07-13 | 2022-08-16 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2022-07-13 | 2022-08-16 | N |
| Develop a communication plan. | Fire Safety | 2022-07-13 | 2022-08-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-07-13 | 2022-08-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-07-13 | 2022-08-16 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-07-13 | 2022-08-16 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-07-27 | 2022-08-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-27 | 2022-08-15 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-07-27 | 2022-08-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-07-13 | 2022-08-11 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-07-13 | 2022-08-04 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-06-16 | 2022-07-22 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2022-06-16 | 2022-07-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-06-16 | 2022-07-22 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-06-16 | 2022-07-22 | Y |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-07-13 | 2022-07-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-12 | 2022-05-17 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-04-12 | 2022-05-17 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-02-02 | 2022-03-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-02 | 2022-03-11 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-02-02 | 2022-03-11 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-22 | 2021-12-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-27 | 2021-09-10 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-08-27 | 2021-09-10 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-05-11 | 2021-05-12 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-09-27 | 2019-10-18 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-09-27 | 2019-10-18 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-09-27 | 2019-10-18 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-09-27 | 2019-10-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-27 | 2019-10-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-27 | 2019-10-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-27 | 2019-10-18 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-09-27 | 2019-10-18 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-09-27 | 2019-10-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-26 | 2019-10-17 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-09-27 | 2019-10-15 | N |
| Respond appropriately to all alleged violations. | Health | 2019-09-27 | 2019-10-15 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-09-27 | 2019-10-15 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-09-27 | 2019-10-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-27 | 2019-10-15 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-09-27 | 2019-10-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-27 | 2019-09-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-27 | 2019-09-28 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-09-26 | 2019-09-26 | N |
