Washington Square Healthcare Center

Inspectors wroteBased on record review, hospital record review, review of email communication, policy review and interview, the facility failed to readmit Resident #69 during the appeal of a discharge notice. After issuing a discharge notice, the resident became distressed, made threats toward the Administrator, and was hospitalized for psychiatric evaluation. Once stabilized and cleared by hospital staff, the facility refused timely readmission and did not provide required documentation showing an inability to meet the resident's ongoing needs or a safe long-term discharge plan, leaving the resident without appropriate long-term placement. This affected one resident (#69) of three residents reviewed for discharge. The facility census was 68.

Inspectors wroteBased on record review and interview, the facility failed to demonstrate effective leadership of the overall facility operations to ensure each resident attained/maintained their highest practicable physical, mental, and psychosocial well-being. This had the potential to affect all 74 residents residing in the facility.

Inspectors wroteBased on record review, interview, and review of facility policy, facility staff failed to report allegations of rights violations, misappropriation, neglect and/or abuse in a timely manner. This affected seven residents (Residents #18, #32, #43, #72, #75, #79 and #80) out of 11 residents reviewed for reporting of abuse and/or resident rights violations. This had the potential to affect 32 residents residing in the [NAME] Unit (Residents #1, #3, #4, #5, #6, #9, #12, #13, #16, #18, #21, #22, #27, #28, #33, #34, #35, #38, #39, #40, #42, #43, #47, #49, #51, #55, #60, #63, #68, #69, #72 and #73) and 25 residents (Residents #1, #3, #8, #11, #12, #15, #16, #27, #28, #31, #32, #36, #37, #39, #41, #42, #44, #46, #49, #54, #60, #69, #70, #72 and #73) identified on insulin. The facility census was 74.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure resident rights were maintained. This affected one Resident (#43) out of 11 residents reviewed for resident rights. The facility census was 74.

Inspectors wroteBased on record review, interview, review of a Self-Reported Incident (SRI) and facility policy, the facility failed to timely investigate into allegations that led to misappropriation of insulin. This affected four residents (Residents #12, #15, #16 and #32) out of five residents reviewed for misappropriation of their insulin. This had the potential to affect 25 residents (Residents #1, #3, #8, #11, #12, #15, #16, #27, #28, #31, #32, #36, #37, #39, #41, #42, #44, #46, #49, #54, #60, #69, #70, #72 and #73) identified on insulin. The facility census was 74.

Inspectors wroteBased on record review, interview, and review of a Self-Reported Incident (SRI) and facility policy, the facility failed to provide insulin to residents using accepted standards of clinical practice. This affected four residents (Residents #12, #15, #16 and #32) out of five residents reviewed for diabetic care. This had the potential to affect 25 residents (Residents #1, #3, #8, #11, #12, #15, #16, #27, #28, #31, #32, #36, #37, #39, #41, #42, #44, #46, #49, #54, #60, #69, #70, #72 and #73) identified on insulin. The facility census was 74.

Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility failed to provide showers for residents dependent on staff for activities of daily living (ADL) per their preference and/or as scheduled. This affected two residents (Residents #25 and #70) out of three residents reviewed for ADL care. This had the potential to affect 35 residents (Residents #1, #3, #5, #8, #13, #15, #19, #20, #21, #22, #23, #24, #25, 27, #29, #32, #33, #42, #44, #47, #48, #49, #50, #54, #55, #56, #57, #59, #60, #62, #66, #69, #70, #71 and #72) dependent on staff for ADL care including showers. The facility census was 74.

Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility failed to ensure ostomy care was provided as recommended. This affected two residents (Residents #70 and #77) out of three residents reviewed for ostomy care. This had the potential to affect five Residents (#36, #48, #61, #70 and #77) who the facility identified with ostomies. The facility census was 74.

Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility failed to ensure residents were free of significant medication errors. This affected two residents (Residents #32 and #73) out of eight residents reviewed for medication administration. The facility census was 74.

Inspectors wroteBased on record review, interview, and review of facility policy, the facility failed to ensure the medical record contained accurate information. This affected two residents (Residents #32 and #77) out of 11 records reviewed for documentation accuracy. The facility census was 74.

Inspectors wroteBased on observation, interview, record review, review of the Centers for Medicare and Medicaid services (CMS) memorandum QSO-24-08-NH, and review of facility policy, the facility failed to utilize enhanced barrier precautions (EBP) for Resident #54 during high contact resident care. This affected one resident (Resident #54) out of two residents observed for EBP. This had the potential to affect 27 residents (Residents #1, #3, #5, #9, #10, #19, #20, #21, #31, #34, #36, #39, #41, #43, #45, #44, #48, #53, #54, #56, #60, #61, #66, #67, #69 #70 and #73) identified by the facility on EBP.

Inspectors wroteBased on record review, observation, interview and policy review, the facility failed to ensure a resident was properly transported in a wheelchair to prevent injury. Actual harm occurred on 03/13/26 when Resident #5, who had hemiplegia (total loss of voluntary movement of affected muscle resulting in stiffness or spasticity) in his right leg and required a wheelchair for mobility, was transported to an appointment under the supervision of Transporter #719. Transporter #719 failed to maintain proper positioning of Resident #5, causing his right leg to press into the leg rests. His foot also repeatedly hit the ground when being pushed in a wheelchair to his physician appointment. Resident #5 winced in pain and complained of pain in his right leg to the staff at the physician's office. Resident #5 developed bruising and a wound infection of the right leg and was hospitalized on [DATE]. [...]

Inspectors wroteBased on record review, interview, review of the facility Self-Reported Incident (SRI) and review of facility policy, the facility failed to report allegations of abuse to the state agency as required. This affected one (Resident #5) of three residents reviewed for abuse. The facility census was 67.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident representative was immediately notified about a leg injury and failed to ensure proper notification to the representative of an outside medical appointment for Resident #5. This effected one resident ( Resident #5) of six residents ( #3, #5, #30, #31, #41,and #58) reviewed for change in condition. The facility census was 67.

Inspectors wroteBased on record review, review of witness statements, interviews and review of facility policy, the facility failed to ensure Resident #5 was free from verbal abuse by a staff member. This affected one resident (#5) out of three residents reviewed for abuse. The facility census was 67.

Inspectors wroteBased on record review, observation, interview, and review of facility policy the facility failed to coordinate transportation services that were resident centered following a surgical procedure for the highest practicable well-being for Resident #41, and failed to adequately monitor Resident #5 following a change in health status resulting in hospitalization. This affected two residents ( Resident #5 and #41 ) of five residents reviewed for quality of care . The facility census was 67.

Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility failed to ensure Resident #69 was free from a significant medication error. This affected one resident (#69) of three residents reviewed for medication administration. The facility census was 67.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure accurate documentation of blood sugar values. This affected one resident (#69) of three residents reviewed for medication administration. The facility census was 67. Review of Resident #69's medical records revealed an admission date of 12/12/25. Diagnoses included diabetes, hypertension and difficulty walking. Review of care plan dated 03/11/26 revealed Resident #69 had diabetes. Interventions included administer diabetic medications as ordered, monitor/document/report signs and symptoms of hyperglycemia (high blood sugar) that included increased thirst. Review of physician orders for April 2026 included administer Humalog (fast acting insulin) subcutaneously per sliding scale before meals and at bedtime. [...]

Inspectors wroteBased on interviews, review of personnel files and review of the facility corrective action, the facility failed to ensure that all nursing staff were competent and legally licensed to provide nursing care and services to residents. This had the potential to affect all residents residing in the facility. The facility census was 67.

Inspectors wroteBased on record review, and interview the facility failed to demonstrate effective leadership of the overall facility operations to ensure each resident attained/maintained their highest practicable physical, mental, and psychosocial well-being. This affected five residents (#3, #28, #41, #43, and #68) and had the potential to affect all residents in the facility. The facility census was 67.

Inspectors wroteBased on observation, interview, facility records review and facility policy review, the facility failed to ensure the shower room on the [NAME] Unit was maintained in sanitary condition and good repair. This had the potential to affect all 37 (#1, #4, #7,#8, #9, #10, #12, #14, #17, #19, #21, #22, #25, #26, #27, #32, #34, #35, #38, #41, #42, #44, #46, #49, #50, #52, #53, #54, #56, #57, #58, #61, #62, #63, #64, #66, and #67) residents on the [NAME] Unit. The facility census was 67.

Inspectors wroteBased on record review, interview and review of facility policy, the facility failed to ensure all residents were treated with respect and dignity. This affected one resident (Resident #68) out of 11 residents reviewed for resident rights. The facility census was 67.

Inspectors wroteBased on record review, interview and review of facility policy the facility failed to ensure residents were free from misappropriation of narcotics. This affected three residents (Residents #38, #41 and #69) of four residents reviewed for misappropriation of narcotics. The facility census was 67.

Inspectors wroteBased on interview, record review, review of the facility self-reported incident (SRI) and investigation, and policy review the facility failed to ensure allegations of misappropriation of narcotics were thoroughly investigated. This affected three residents (Residents #28, 41 and #69) out of four residents reviewed for misappropriation of narcotics. The facility census was 67.

Inspectors wroteBased on record review, review of care conference meeting documents, resident and staff interview, and review of facility policy, the facility failed to ensure all minimum required members of the Interdisciplinary team were present during care plan meetings. This affected one resident (Resident #41) out of 11 residents reviewed for care plans. The facility census was 67.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure residents were free of significant medication errors. This affected one resident (Resident #70) of 11 residents reviewed for medication administration. The facility census was 67.

Inspectors wroteBased on record review, interviews, review of the facility self-reported incident, and review of facility policy, the facility failed to ensure complete and accurate medical records were maintained for Resident #3 and Resident #43. This affected two residents (Resident #3 and Resident #43) out of 11 residents reviewed for resident records. The facility census was 67.

Inspectors wroteBased on closed record review, staff interviews, and policy review, the facility failed to provide basic life support (BLS), including Cardiopulmonary Resuscitation (CPR) to Resident #61 per the residents advanced directive for a full code status, when the resident was found unresponsive and absent of vital signs. This resulted in Immediate Jeopardy and serious life-threatening harm and the subsequent of death of Resident #61 beginning on [DATE] when Certified Nursing Assistant (CNA) #135 alerted Registered Nurse (RN) #142 Resident #61was absent of vital signs. Instead of providing immediate care (i.e. CPR) RN #142 assessed the resident to be absent of vital signs and contacted Licensed Practical Nurse (LPN) #136 who was working another unit to verify the resident ' s death. RN #142 pronounced the resident ' s time of death of 4:50 P.M. [...]

Inspectors wroteBased on closed medical record review, facility policy and procedure review and interviews, the facility failed to provide timely, necessary and adequate care and services following an acute change in condition involving Resident #61 that started on [DATE]. The facility failed to ensure changes in the residents ' medical condition were comprehensively assessed, the residents change in condition, including abnormal vital signs and extreme loss of balance, was communicated to the medical provider, and individualized interventions were implemented. [...]

Inspectors wroteBased on interviews and record review the facility failed to ensure residents were treated with dignity and respect. This affected one Resident (Resident #19) out of three residents reviewed for dignity and respect. The facility census was 60.

Inspectors wroteBased on record review and interview, the facility did not ensure a comprehensive, person-centered care plan was developed to address individual needs and preferences related to insulin administration for Resident #19. This affected one resident (Resident #19) of 11 residents reviewed for care plans. The facility census was 60.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure one resident (Resident #19) received her insulin as ordered. This affected one resident (Resident #19) of three residents reviewed for medication administration. The facility census was 60.

Inspectors wroteBased on record review and interview the facility did not ensure lab results were timely reported to the physician. This affected one resident (#19) out of three residents reviewed for lab services. The facility census was 60.

Inspectors wroteBased on record review and interview the facility did not ensure a complete and accurate medical record for Resident #19. This affected one resident (Resident #19) out of 11 residents reviewed for complete and accurate medical record. The facility census was 60.

Inspectors wroteBased on record review, interview and observation, the facility failed to ensure a safe, functional and comfortable environment for residents, staff and the public. This had the potential to affect 14 residents (Residents #2, #5, #12, #15, #21, #25, #27, #32, #42, #47, #48, #49, #53 and #57) who resided on the [NAME] unit, out of 60 residents observed for physical environment. The facility census was 60.

Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility failed to ensure medications were disposed of timely when discontinued or a resident was discharged . This had the potential to affect all 29 residents residing on the [NAME] Unit (Residents #2, #3, #4, #6, #8, #16, #19, #20, #26, #31, #35, #36, #38, #39, #40, #41, #42, #43, #45, #46, #47, #49, #52, #62, #116, #117, #118, #120 and #267). The facility census was 62.

Inspectors wroteBased on observation, interview and review of facility policy, the facility failed to maintain a safe, functional, sanitary and comfortable environment. This had the potential to affect all 29 residents (Residents #2, #3, #4, #6, #8, #16, #19, #20, #26, #31, #35, #36, #38, #39, #40, #41, #42, #43, #45, #46, #47, #49, #52, #62, #116, #117, #118, #120 and #267) who resided on the [NAME] Unit, one resident ( Resident #1) on the [NAME] Unit, and an additional 13 residents (Residents 9, #11, #27, #23, #48, #22, #29, #17, #37, #28, #59, #53, #62) the facility identified as residents who smoke. The facility census was 62.

Inspectors wroteBased on record review, interview and review of facility policy, the facility did not ensure a comprehensive care plan was developed to include the need for Enhanced Barrier Precautions (EBP) for Resident #267. This affected one resident (#267) of 25 residents reviewed for care plans. The facility census was 62.

Inspectors wroteBased on observation, record review, interview and review of facility policy the facility failed to ensure enhanced barrier precautions (EBP) were implemented for Resident #216 and Resident #267. This affected two residents (#216 and #267) of 21 residents (Resident #36, #35, #45, #46, #34, #6, #47, #40, #38 #2, #51, #7,#36, #48, #5, #32, #33, #53, #118, #216 and #267 ) the facility identified as requiring EBP. The facility census was 62.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview, review of Self-Reported Incident (SRI) tracking number (#)240669, review of a personnel file, and facility policy review the facility failed to prevent misappropriation of a narcotic medication for Resident #56. This affected one resident (#56) of one resident reviewed for misappropriation of property. The facility census was 60.

Inspectors wroteBased on closed record review, facility policy review and interview the facility failed to ensure routine assessment/skin monitoring was completed and failed to prevent the development of an avoidable pressure ulcer injury for Resident #68. Following the development of the pressure ulcer, the facility failed to ensure treatments were completed as ordered. Actual Harm occurred on 07/19/23 when Resident #68, who was assessed to be at risk for pressure ulcer development was found to have an open wound (to the left lateral foot) with no evidence of any type of treatment being initiated. On 07/20/23 the area was assessed to be unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) pressure ulcer. This affected one resident (#68) of three reviewed for wounds. [...]

Inspectors wroteBased on observations, staff interviews, record review, and facility policy review the facility failed to provide adequate supervision to prevent elopement of Resident #10. This affected one resident (#10) of one resident reviewed for elopement. The facility census was 61.

Inspectors wroteBased on observations, record review, and interview, the facility failed to ensure menus included a variety of food and failed to ensure menus and recipes were followed. This affected all residents except Resident #35 who received nothing by mouth. The facility census was 65.

Inspectors wroteBased on record review, interview, policy and procedure review, and review of the Centers for Disease Control guidelines, the facility failed to ensure all employees were administered a baseline Tuberculosis (TB) test on hire. This had the potential to affect all 65 residents in the facility.

Inspectors wroteBased observation and interview the facility failed to maintain comfortable temperature levels. This affected five (Residents #13, #17, #28, #31 and #44) of 15 residents whose rooms were observed for comfortable temperatures.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the pureed sloppy joe was properly prepared and of the correct consistency. This had the potential to affect 13 residents (#4, #6, #10, #20, #22, #26, #29, #39, #41, #46, #52, #74, and #119) of 13 residents who received a pureed diet. The facility census was 65.

Inspectors wroteBased on observation and interviews, the facility failed to ensure resident meal choices were obtained consistently. This affected 13 residents (#11, #14, #17, #18, #23, #32, #36, #42, #58, #59, #61, #63, and #76) and had the potential to affect all residents except Resident #35 who received nothing by mouth.

Inspectors wroteBased on observation and interview, the facility failed to ensure meals were served in a sanitary manner. This had the potential to affect all residents except Residents #4, #6, #10, #20, #22, #26, #29, #39, #41, #46, #52, #74, and #119 who received a pureed diet and Resident #35 who received nothing by mouth. The facility census was 65.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Long Term Care Ombudsman received copies of hospital transfer notices. This affected two residents (#13 and #66) of two residents reviewed for hospitalizations. The facility census was 65.

Inspectors wroteBased on record review and interview, the facility failed to ensure care plans were developed for hospice and dialysis services. This affected Resident #45 who received hospice services and Resident #63 who received dialysis services. This affected one (Resident #45) of one resident reviewed for hospice and one (Resident #63) of one resident reviewed for dialysis. The facility census was 65.

Inspectors wroteBased on record review, observation, interview and review of manufacturer instructions the facility failed to ensure Resident #32 was prompted or assisted to rinse mouth with water and expectorate to help reduce the risk of orophayrngeal yeast infection after administration of inhaled medication. This affected one (Resident #32) of five residents observed during medication administration. The census was 65.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure oxygen tubing was changed in a timely manner. This affected one resident (#52) of one resident reviewed for respiratory care. The facility census was 65.

Inspectors wroteBased on record review and interview, the facility failed to ensure pre and post dialysis assessments were completed for one resident (Resident #63). This affected one of one resident (Resident #63) reviewed for dialysis and one of eight resident reviewed for assessments. The facility census was 65.

Inspectors wroteBased on record review and interview, the facility failed to ensure the attending physician documented the rational when pharmacy recommendations were not accepted and no medication changes were made. This affected two out of seven residents reviewed for unnecessary medications (Resident #5 and Resident #8). The facility census was 65.

Inspectors wroteBased on observation and interview the facility failed to ensure medications were labeled with name of medication, expiration date, and cautionary instructions as applicable. This had the potential to affect 34 (Resident #2, #4, #5, #6, #7, #10, #11, #15, #16, #17, #18, #19, #20, #22, #25, #26, #27, #29, #30, #34, #35, #37, #41, #45, #46, #49, #51, #54, #55, #57, #58, #61, #63, and Resident #219) of 34 residents residing on the [NAME] unit. The census was 65.

Inspectors wroteBased on record review and interview, the facility failed to ensure Residents #39 and #48's comprehensive assessments were accurate. This finding affected two (Residents #39 and #48) of twenty-one resident records reviewed. The facility census was 54.

Inspectors wroteBased on interview and record review, the facility failed to monitor Resident #30's bowel movements and follow the facility bowel protocol ordered per her physician. This affected one resident (Resident #30) of one resident reviewed for constipation. The facility census was 54.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Resident #21's oxygen was administered per the physician orders. This affected one (Resident #21) of four residents reviewed for respiratory care and had the potential to affect four additional residents (Residents #16, #37, #45, and #50) who required oxygen therapy. The facility census is 54.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure State Tested Nursing Assistants (STNA) provided care within their scope of practice. This finding affected one (Resident #21) of four residents reviewed for oxygen therapy and had the potential to affect four additional residents (Residents #16, #37, #45, and #50) who required oxygen therapy. The facility census was 54.

Inspectors wroteBased on record review and interview, the facility failed to ensure Residents #39, #45 and #51 and/or the resident's representative were notified in writing the reason for the discharge to the hospital in an easily understood language. This finding affected three (Residents #39, #45 and #51) of three resident records reviewed for hospitalization. The facility census was 54.

Inspectors wroteBased on record review and interview, the facility failed to ensure Residents #39, #45 and #51 and/or the resident's representative were provided written notice of the bed-hold policy and reserve bed payment at the time of transfer or within twenty-four hours of transfer to the hospital. This finding affected three (Residents #39, #45 and #51) of three resident records reviewed for hospitalization. The facility census was 54.