Washington Center for Rehab and Healthcare

Inspectors wroteBased on record review and interviews conducted during the recertification and abbreviated survey (Case # 677094), the facility failed to ensure the residents' right to be free from neglect for one (1) (Resident #128) of six (6) residents reviewed for neglect. Specifically, Resident #128 was care planned for falls with intervention including the resident's bed being in the lower position, bolsters placed on both sides, and high-profile floor mats. On 02/12/2025, Certified Nurse Aide #2 left the resident unattended with the bed in a high position while providing care. The resident fell out of bed and sustained a hematoma (a localized pool of blood) on the head, and bruising in both knees. This resulted in actual harm to Resident #128 that was not Immediate Jeopardy. [...]

Inspectors wroteBased on record review and interviews conducted during the recertification survey, the facility did not ensure each resident was treated with respect and dignity in a manner and environment that promoted maintenance or enhancement of their quality of life for one (1) (Resident #22) of six (6) residents reviewed. Specifically, Resident #22 reported that some staff did not treat them with respect, they were impolite and mean to them. The resident expressed concern over being treated worse if they talked about it. This is evidenced by: The Policy and Procedure titled, Quality of Life/Dignity, revised 5/28/2024, documented each resident would be cared for in a manner that promoted or enhanced quality of life, dignity, respect and individuality. Residents would be treated with dignity and respect at all times. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during a recertification survey, the facility did not ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice and the comprehensive person-centered care plan for one (1) (Resident #2) of two (2) residents reviewed for respiratory care. Specifically, for Resident #2, the facility did not ensure the physician's order for oxygen administration was followed. This is evidenced by: The Policy and Procedure titled, Oxygen - concentrators, dated 8/14/2025, documented that oxygen equipment would be checked daily for the correct flow and concentration. The Policy and Procedure titled, Oxygen Policy, dated 8/13/2025, stated the oxygen flow rate must be adjusted by a Licensed Practical Nurse and administered according to the physician order. [...]

Inspectors wroteBased on observation and staff interview conducted during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, the trash compactor was leaking and the area around was not clean. This is evidenced by: During observations on 09/08/2025 at 11:25 AM, a white and yellow fluid and a black fluid were leaking from the trash compactor. A food decomposition odor was detected in the area surrounding the compactor. During an interview on 09/08/2025 at 11:26 AM, Food Service Director #1 stated that they would place a work order with the maintenance department to contact the vendor to have the compactor replaced or repaired and to have the area cleaned. New York Codes, Rules, and Regulations Title 10 S415.14(h)

Inspectors wroteBased on record reviews and interviews conducted during an abbreviated survey (Complaint #NY00304653), the facility did not ensure the resident's right to be free from neglect for 1 (Resident #1) of 4 residents reviewed for abuse. Specifically, Resident #1 who required mechanical lift for transfers was transferred with a wheeled walker from a shower chair to bed by a Certified Nurse Aide. Resident #1's knees buckled, lowered to the floor, and sustained bilateral knees skin tears. This is evidenced by: Resident #1 Resident #1 was admitted to the facility with diagnoses of cellulitis, acute embolism, and thrombosis (blood flow obstruction) deep veins of an extremity, and chronic atrial fibrillation. [...]

Inspectors wroteBased on record review and interviews during an recertification and abbreviated survey (Case #'s NY00258873, NY00269351, NY00269396, NY00279095, NY00285004, NY00289838, and NY00294513) conducted on 9/07 through 9/13/2022, the facility did not ensure that a Level II assessment was conducted as indicated on the DOH-695 (2/2009) Screen form, prior to admission for one (Resident # 117) of 18 residents reviewed for completion of PASRR (Preadmission Screen Resident Review). Specifically, for Resident #117, whose DOH-695 (2/2009) Screen form dated 6/9/2021 indicated the resident was to have a Level II Evaluation completed for determination of needed services due to the diagnosis of Intellectual Disability, the facility did not ensure the Level II Evaluation was done. This is evidenced by: [...]

Inspectors wroteBased on observation, record review and interviews during a recertification survey and abbreviated survey (Case #NY245216), the facility did not ensure residents were free from physical abuse for 2 (Resident #'s 19 and 67) of 3 residents reviewed for abuse. Specifically, the facility did not ensure that Resident #'s 19 and 67 were free from physical abuse related to a resident to resident altercation. This was evidenced by: Resident #67: Resident #67 was admitted to the facility with diagnoses of Cerebral Vascular Accident (CVA) with hemiplegia and hemiparesis, Congestive Heart Failure (CHF) and Chronic Obstructive Pulmonary Disease (COPD). The Minimum Data Set (MDS-an assessment tool) dated 9/17/19, documented the resident had severe cognitive impairment, could usually understand others and was usually able to make himself understood. [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey, the facility did not ensure acceptable parameters of nutrition were maintained for 2 (Resident #'s 80 and 115) of 3 resident reviewed for nutrition. Specifically, for Resident #80, the facility did not ensure a resident with a significant weight loss received adaptive equipment and assistance eating in accordance with the comprehensive care plan; and for Resident #115, the facility did not ensure the resident received a physician ordered supplement in accordance with the comprehensive care plan and the resident's preference. This is evidenced by: [...]

Inspectors wroteBased on record review and interviews during the recertification survey, the facility did not ensure that residents who require dialysis receive such services, consistent with professional standards of practice for 1 (Resident #115) of 1 residents reviewed for dialysis care. Specifically, the facility did not ensure there was ongoing communication with the dialysis treatment center. This is evidenced by: The Policy and Procedure (P&P) titled Dialysis Management, dated 5/2019, documented the facility was to establish communication with the dialysis center using the dialysis communication form. The P&P documented the nurse would establish pre-dialysis vital signs, advanced directives, and any pertinent resident information and the nurse would review the communication when the resident returned from the dialysis center. [...]

Inspectors wroteBased on record review and interviews during the recertification survey, the facility did not ensure qualified staff were employed to carry out food and nutrition services. Specifically, the facility did not ensure that when a qualified dietitian was not employed full-time, the person designated to serve as the Director of Food and Nutrition met the requirements. This is evidenced by: The Facility Survey Report (FSR) dated 1/6/20, did not include documentation of the Food Service Director (FSD) qualifications. The FSR documented the qualified dietitian was part time. The facility assessment, reviewed by the Food Service Director (FSD) on 9/19/19, documented the Registered Dietitian position would be staffed as follows: 0.4 FTE's, 5 days a week, 2 shifts per week, 19 hours total. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, carbon monoxide detection was not provided in accordance with adopted regulation. The International Fire Code, 2015 Edition Section 915 Carbon Monoxide Detection, requires carbon monoxide detection in all areas with gas operated equipment. Specifically, carbon monoxide detection was not installed in areas with gas fuel fired equipment. This is evidenced as follows. Observations on 01/06/2020 at 1:00 PM, revealed fuel burning appliance in the basement boiler room, laundry room, and the kitchen without carbon monoxide detection. The Director of Maintenance stated in an interview on 01/06/2020 at 1:15 PM, that he will add carbon monoxide protection in all areas with gas fuel fired equipment. 483.70 (b); 2015 International Fire Code, Section 915

Inspectors wroteBased on observation, interview and record review during a recertification survey, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infection. Specifically, face masks were not properly worn by three employees while on resident units. This is evidenced by: Policy Statement on Influenza Vaccination of Health Care Personnel dated 8/09/19, documented it is recommended that health care personnel who do not receive an influenza vaccination must wear personal-protective masks when in direct resident contact during the influenza season (October through April). It is also recommended to target education to any health care personnel who do not receive an influenza vaccination. [...]