Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Washington County Nursing Home during CMS and state inspections, most recent first.
A resident with type 2 DM, CKD, and severe cognitive impairment had a blood sugar of 439 mg/dL, after which the physician ordered 5 units of Lantus SC daily. Following administration of this new long-acting insulin, there was no documented blood glucose monitoring to assess treatment effectiveness or to detect potential side effects. The DON confirmed that there was no follow-up re-evaluation or documentation of the incident or the order in the resident’s EHR, despite the known risk of hypoglycemia associated with Lantus.
The facility failed to follow infection control practices for insulin administration when an LPN used one resident’s Lantus insulin pen to inject another resident, despite CDC guidance and facility policy stating insulin pens are for single-patient use only. The affected resident had type 2 DM, chronic kidney disease, and dementia with severe cognitive impairment and required assistance with ADLs. When the ordered insulin was not found in the emergency kit, the LPN used another resident’s pen instead of obtaining the medication through STAT pharmacy delivery or nearby hospitals, resulting in noncompliance with established infection prevention standards.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their medical needs. A resident on anticoagulants lacked a care plan for monitoring side effects. Another resident requiring supplemental oxygen had no care plan focus on its use, and the Kardex lacked documentation on oxygen flow rate. A third resident on diuretics had no care plan addressing the medication or chronic kidney disease. Staff interviews revealed a lack of clarity and oversight in care planning responsibilities.
A resident with moderate cognitive impairments and a history of falls felt her dignity was compromised by motion sensor alarms that restricted her movements and alerted the entire facility. Despite the alarms frequently activating, staff did not discuss their impact on her well-being. Observations confirmed the presence of alarms, and staff interviews revealed a lack of awareness about the resident's feelings, indicating a deficiency in maintaining her dignity and self-determination.
A facility failed to monitor and document side effects for a resident on anticoagulant therapy, as required by their policy. The resident, with severe cognitive impairment and on Eliquis for conditions like atrial fibrillation, had no care plan addressing the medication's use or side effects. Staff interviews revealed a lack of adherence to monitoring protocols, with the LPN unable to recall necessary signs and the DON confirming the absence of monitoring.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a urinary catheter, as required by CDC guidelines. Staff interviews revealed a lack of understanding and implementation of EBP, with only gloves being used for catheter care. The infection preventionist and nursing home administrator were unaware of EBP requirements, and the resident's electronic medical record lacked documentation of EBP or PPE use.
Failure to Monitor Blood Glucose After Initiation of Long-Acting Insulin
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice after initiation of a new long-acting insulin order. The resident, who had type 2 diabetes mellitus with diabetic chronic kidney disease and unspecified dementia with severe cognitive impairment (BIMS score of 6/15), had a documented blood sugar of 439 mg/dL on 1/8/26. Following this elevated blood sugar result, the physician ordered Lantus insulin glargine 5 units subcutaneously once daily for type 2 diabetes. Lantus is a long-acting insulin whose most common side effect, as noted in the manufacturer’s information, is hypoglycemia, which may be serious and life threatening. Record review of the resident’s EMR showed no documentation that the resident’s blood sugar was monitored after administration of the newly prescribed Lantus to evaluate the effectiveness of the treatment or to monitor for possible side effects. The DON confirmed that there was no follow-up re-evaluation of the elevated blood sugar after the 5 units of Lantus were given by the LPN, and also confirmed there was no documentation of the incident or receipt of the order in the resident’s electronic health record. The physician stated that the nurse had called to report the high blood sugar and that she ordered the 5 units of Lantus, but there was no subsequent documented monitoring of the resident’s blood sugar following administration.
Improper Insulin Pen Use for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program when administering insulin via an insulin pen. Facility policy dated November 2025 and CDC guidance both state that insulin pens are for single-patient use only and must never be used for more than one person. Despite this, an LPN obtained an insulin pen prescribed for one resident and used it to administer Lantus insulin to another resident, using a new needle but the same pen. The facility’s own investigation documented that the LPN used another resident’s insulin pen after not finding Lantus in the emergency kit. Resident #1, an older adult with type 2 diabetes mellitus with diabetic chronic kidney disease and unspecified dementia with mood disturbance, had severe cognitive impairment with a BIMS score of six and required partial to moderate assistance with activities of daily living. A recent MDS indicated a change in the insulin order for this resident. When the ordered Lantus was not available in the emergency kit, the LPN chose to use another resident’s insulin pen instead of obtaining the medication through other available means, such as STAT pharmacy delivery or nearby hospitals, as described by another LPN. This action directly violated CDC guidance and the facility’s insulin pen use policy, resulting in a failure to follow proper infection control practices during insulin administration.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in addressing their specific medical needs. Resident #38, who had severe cognitive impairment and required assistance with daily activities, was on an anticoagulant medication, Eliquis, due to conditions like atrial fibrillation and a history of thrombosis. However, there was no care plan in place to monitor the use of this medication or its potential side effects, such as excessive bruising or bleeding. Interviews with staff revealed a lack of clarity on the necessity of a care plan for anticoagulant use, with the Director of Nursing acknowledging the oversight. Resident #24, diagnosed with conditions including Parkinson's and dementia, required supplemental oxygen. Despite physician orders specifying oxygen use, the resident's care plan did not include a focus on supplemental oxygen, and the Kardex used by CNAs lacked documentation on the oxygen flow rate. Staff interviews highlighted reliance on verbal reports for oxygen administration details, with the Director of Nursing confirming that care plans should include all aspects of care, including oxygen use. Resident #3, with significant cognitive impairment and chronic kidney disease, was prescribed Lasix, a diuretic medication, for edema. The care plan did not address the use of diuretics or the resident's chronic kidney disease, despite the potential risks of dehydration or fluid overload. Staff interviews indicated that while the ADON maintained most care plans, there was no specific focus on medications like diuretics, which was acknowledged as important by the ADON. The lack of comprehensive care plans for these residents reflects a systemic issue in ensuring all medical needs and treatments are adequately documented and monitored.
Failure to Address Resident's Concerns About Motion Sensor Alarms
Penalty
Summary
The facility failed to uphold the dignity and respect of a resident by not discussing the impact of a fall intervention sensor alarm on her well-being. The resident, who had moderate cognitive impairments and a history of falls, expressed feeling different from other residents due to the use of motion sensor alarms that restricted her movements. These alarms were placed at the foot of her bed and across the room, activating whenever she attempted to reposition herself, which made her feel uncomfortable and exposed. Interviews with the resident revealed that the alarms were audible throughout the facility, alerting everyone to her movements, which she found distressing. Despite the frequent activation of these alarms, no staff member had inquired about how they affected her emotionally. Observations confirmed the presence of two motion sensor alarms in her room, and staff interviews indicated a lack of awareness regarding the resident's feelings about the alarms. The facility's staff, including the Director of Nursing and the Nursing Home Administrator, admitted to not having assessed the resident's feelings about the alarms since their implementation. The Social Services Director also confirmed not having discussed the matter with the resident. This oversight highlights a deficiency in the facility's approach to maintaining the resident's dignity and self-determination, as they failed to engage with her about the impact of the alarms on her quality of life.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure that the drug regimen for one resident was free from unnecessary medications, specifically in the monitoring and documentation of side effects for an anticoagulant medication. The facility's policy required monitoring for adverse drug reactions and complications related to anticoagulant use, such as excessive bruising or bleeding. However, the resident's care plan did not address the use of the anticoagulant or its potential side effects, and there was no documentation of monitoring for these side effects. The resident in question, who was over 65 years old and had severe cognitive impairment, was on a prescribed anticoagulant, Eliquis, due to conditions like atrial fibrillation and a history of thrombosis. Interviews with staff revealed a lack of awareness and adherence to the facility's policy on monitoring anticoagulant side effects. The LPN could not recall all the signs to monitor, and the DON acknowledged the importance of monitoring but confirmed that it was not being done. The NHA also emphasized the need for a care plan to address monitoring for side effects, which was absent in this case.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection control program, specifically in the implementation of Enhanced Barrier Precautions (EBP) for a resident with a urinary catheter. The Centers for Disease Control and Prevention (CDC) guidelines for EBP, which include the use of gowns and gloves during high-contact resident care activities, were not followed. The facility's policy did not include specifics for EBP, and there was no evidence of personal protective equipment (PPE) being used or available in the resident's room during observations. Interviews with staff revealed a lack of understanding and implementation of EBP. A certified nurse aide (CNA) and a licensed practical nurse (LPN) both indicated that they only used gloves for catheter care and were unaware of the need for additional PPE unless an infection was present. The infection preventionist and nursing home administrator also lacked knowledge about EBP and acknowledged the absence of a system to notify staff if residents were on EBP. The resident's electronic medical record did not document the use of EBP or PPE, further indicating a gap in the facility's infection control practices.
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