Washington Square Healthcare Center

In the surveyor’s words

From the most serious findings on record at Washington Square Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Jul 17, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF684Jul 17, 2025

  Based 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. […]

• Actual harm, isolatedF689Apr 20, 2026

  Based 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. […]

• Actual harm, isolatedF686Oct 5, 2023

  Based 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. […]

• No harm, potential for more than minimal, widespreadF835May 29, 2026

  Based 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.Findings include:Review of the job description for Registered Nurse (RN)/Assistant Director of Nursing (ADON) revealed it was signed by RN/ADON #663 on 05/08/25. […]