Washington Square Healthcare Center

was calling the police.

She had used that as an educational moment that she could not do that but

verified it had not been reported to her by RN #648 or to any other management regarding Resident

that RN #648 felt LPN #620 threatened Resident #43.Interview on 05/19/26 at 4:35 P.M. with Regional Nurse #696 and RN #648 who came into the facility to speak with this surveyor revealed Regional Nurse #696 stated RN #648 had not felt LPN #620 was threatening Resident #43.

This surveyor read aloud her interview and after reading it, RN #648 stated, That is correct.

Then Regional Nurse #696 stated to RN #648, I thought you said LPN #620 did not threaten him, and then RN #648 stated, Yes she did not threaten him. RN #648 then continued stating she felt it was Resident #43's home and he had the right to be on any unit and should not be told to leave the unit or if he did not the police would be called. RN #648 verified again Resident #43 was calm that morning and had not said anything to LPN #620.Review of facility policy labeled, Resident Rights Policy and Procedure, dated 2026 revealed the purpose of the policy was to ensure the preservation of every resident's right to a dignified exitance, self-determination, and communication with and access to persons and services inside and outside the facility.

Every resident had the right to be treated with respect and dignity including the right to be free from any psychical or chemical restraints imposed for purposes of discipline or convenience.

Also, each resident had the right to interact with members of the community both inside and outside of the facility.Review of facility policy labeled, Residents Right to Freedom from Abuse, Neglect, and Exploitation, dated 2026 revealed residents were free from abuse, neglect, misappropriation of their property and exploitation.

When the facility had identified abuse the facility would take all appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately, reporting the alleged violation and investigation within required timeframes pursuant to Federal and State statutes and regulations.

This deficiency represents non-compliance investigated under Complaint Numbers 2991563 and 2993004 and is a recite to the complaint survey completed 04/20/26.

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Washington Square Healthcare Center 202 Washington Street NW Warren, OH 44483

who I borrowed from just went through the cart until found whoever I could find with the same insulin

RN/ADON #663 and she was aware the facility was out of insulin syringes and that the nurses were

#620 revealed she most likely did take Resident #32's insulin or gave her someone else's insulin.

Interview on 05/19/26 at 11:21 A.M. with LPN #674 revealed for about a week the facility was without insulin syringes and that she did take another resident's unopened insulin injection pen and administer it to another resident.

She had placed that resident's name on the insulin pen.

She could not remember whose insulin pen she took from and who she gave it to.Interview on 05/19/26 at 11:29 A.M. with LPN #675 revealed she had taken other residents' insulin to administer to other residents as residents did not have their insulin as ordered.

She stated, I know it is wrong. I just do not really have a choice as they need their insulin.

She revealed she knew she took Resident #12's insulin vial and gave it to Resident #15 or it was the other way around as one of them did not have any insulin. LPN #675 verified she had taken other residents' insulin and gave it to other residents but could not remember the exact residents she did.

Interview on 05/19/26 at 2:08 P.M. with RN/ADON #663 revealed she completed the ordering of supplies including insulin syringes.

She stated nobody had brought to her attention that the facility was out of syringes.

She became aware of the concern about a week ago when Ombudsman #698 contacted the facility that a nurse had reported to them the facility was out of insulin syringes.

She revealed the facility had syringes and she placed an extra box in her office that the nurses had access to as back up.

She was not aware that nurses were taking and administering residents' insulin that belonged to another resident.Interview on 05/19/26 at 2:32 P.M. and 05/26/26 at 12:58 P.M. with DON revealed she had received notification from the Ombudsman #698 on 05/13/26 of concern of not having insulin syringes in the building and verified she did not interview any residents and/or nurses if there was a concern with not getting their insulin and/or not having insulin syringes to provide insulin as ordered and/or investigate further besides checking if the facility currently had insulin syringes.

She revealed as of 05/26/26 they had investigated regarding nurses taking other residents' insulin and administering to other residents and LPN #620 and LPN #675 had stated they did.

She did not have witness statements from the nurses as they had stated it verbally on investigation.

She revealed LPN #620 and LPN #675 were terminated for misappropriation.

Interview on 05/19/26 at 3:01 P.M. with Ombudsman #698 revealed it was reported to her by Resident #32 that the facility was out of insulin syringes and they were borrowing insulin pens from other residents.

She revealed they sent the facility an email regarding the concern on 05/13/26.Review of SRI #274748 dated 05/19/26 at 8:34 P.M. revealed an SRI was filed by the Administrator regarding an allegation of misappropriation involving LPN #620 and LPN #675 taking insulin from Resident #12 and giving the insulin to another resident (Resident #16).

The SRI revealed LPN #620 and LPN #675 took insulin from residents without their consent.Review of witness statement dated 05/22/26 at 11:33 A.M. with Resident #16 completed by Administrator from other Facility #700 revealed he could not get his insulin at one point because there were no syringes and he stated he did get it by the end of the day.Interview on 05/26/26 at 12:07 P.M. with Resident #16 revealed he missed his insulin one day as the facility did not have syringes and that he had an agency nurse. He stated the other days when they were out of insulin syringes the regular nurses took insulin from another resident and gave it to him, so he did not miss his insulin.Review of facility policy labeled, Resident Right to Freedom from Abuse, Neglect, and Exploitation, dated 2026 revealed residents were to be free from abuse, neglect, misappropriation of their property and exploitation.

The facility would conduct a thorough investigation of the alleged violation.

This deficiency represents non-compliance investigated under Complaint Number 2991563 and is a recite to the complaint survey completed 03/25/26.

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Washington Square Healthcare Center 202 Washington Street NW Warren, OH 44483

Review of SRI #274748 dated 05/19/26 at 8:34 P.M. revealed an SRI was filed by the Administrator regarding an allegation of misappropriation involving LPN #620 and LPN #675 taking insulin from Resident #12 and giving the insulin to another resident (Resident #16).

The SRI revealed LPN #620 and LPN #675 took insulin from residents without their consent.

Interview on 05/20/26 at 11:38 A.M. with RN #635 revealed the last day she worked she heard the facility was out of insulin syringes.

She had to borrow at times other residents' insulin for another resident as they were out but was unable to remember who she had borrowed from.

Review of witness statement dated 05/22/26 at 11:33 A.M. with Resident #16 completed by Administrator from other Facility #700 revealed he could not get his insulin at one point because there were no syringes and he stated he did get it by the end of the day.

Interview on 05/26/26 at 12:07 P.M. with Resident #16 revealed he missed his insulin one day as the facility did not have syringes and that he had an agency nurse. He stated the other days when they were out of insulin syringes the regular nurses took insulin from another resident and gave it to him, so he did not miss his insulin.

Interview on 05/26/26 at 12:58 P.M. with DON revealed they had investigated regarding nurses taking other residents' insulin and administering it to other residents and LPN #620 and LPN #675 had stated they did.

She stated she did not have witness statements from them as they had stated it verbally on investigation. LPN #620 and LPN #675 were terminated for misappropriation.

Review of facility policy labeled, Administering Medications, dated April 2019 revealed insulin pens containing multiple doses of insulin are for single-resident use only.

Changing the needle does not make it safe to use insulin pens for more than one resident.This deficiency represents non-compliance investigated under Complaint Number 2991563.

365784 05/29/2026

Washington Square Healthcare Center 202 Washington Street NW Warren, OH 44483

Review of facility

would be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs.

Appropriate care and services would be provided for residents who were unable to carry out ADLs independently with the consent of the resident and in accordance with the plan of care including hygiene (bathing).

This deficiency represents non-compliance investigated under Complaint Number 2991563.

365784 05/29/2026

Washington Square Healthcare Center 202 Washington Street NW Warren, OH 44483

Observation of the ostomy bag revealed it had dark brown, black substance surrounding the ostomy appliance and on the bag.

Interview on 05/19/26 at 2:32 P.M. with Director of Nursing verified there were no colostomy orders including monitoring/assessing the stoma site, emptying colostomy bag, and/or changing of the colostomy bag.

She verified she had no documentation as to when Resident #70's bag was changed last.

Review of facility policy labeled, Colostomy/Ileostomy Care, dated October 2010 revealed the purpose of the procedure was to provide guidelines that aided in preventing exposure of the resident's skin to fecal matter.

There was nothing in the policy regarding frequency of changing the ostomy bag, emptying the bag and checking the stoma area.

The policy revealed the following information should be recorded in the resident's record: date and time the ostomy care was provided, if there were any breaks in the resident's skin, signs of infection, and/or excoriation of the skin.This deficiency represents non-compliance investigated under Complaint Number 2993004.

365784 05/29/2026

Washington Square Healthcare Center 202 Washington Street NW Warren, OH 44483

Review of facility policy labeled, Administering Medications, dated April 2019 revealed medications were to be administered in a safe and timely manner as prescribed.

Medications were to be administered in accordance with prescriber orders including required time frames.

Medications were to be administered within one hour of prescribed time unless otherwise specified.

The nurse administering the medication checks the label three times to verify right resident, right medication, right dose, right time, and right method.

This deficiency represents non-compliance investigated under Complaint Number 2991563 and is a recite to the complaint surveys completed 03/25/26 and 04/20/26.

365784 05/29/2026

Washington Square Healthcare Center 202 Washington Street NW Warren, OH 44483

insulin vial and gave it to Resident #15 or it was the other way around as one of them did not have

#698 revealed it was reported to her by Resident #32 that the facility was out of insulin syringes and

at 11:33 A.M. with Resident #16 completed by Administrator from other Facility #700 revealed he could not get his insulin at one point because there were no syringes and he stated he did get it by the end of the day.Interview on 05/26/26 at 12:07 P.M. with Resident #16 revealed he missed his insulin one day as the facility did not have syringes and that he had an agency nurse. He stated the other days when they were out of insulin syringes the regular nurses took insulin from another resident and gave it to him, so he did not miss his insulin.e.

Interview on 05/19/26 at 11:29 A.M. with Licensed Practical Nurse (LPN) #675 revealed residents in the [NAME] unit had prolonged incontinence as residents were not changed for prolonged time as their wheelchair seat cushions were saturated.

She revealed she reported the incident to Registered Nurse (RN)/Assistant Director of Nursing (ADON) #663, and Certified Nursing Assistant (CNA) #638 came in off duty and yelled at her for reporting the situation.

She stated she did find it intimidating especially to come in when not scheduled.

She did let RN/ADON #663 know what CNA #638 did but did not feel anything was done. f.

She revealed Former CNA #702 was having sex with Former Residents #79 and #80 for money.

Former Resident #80 went around stating Former CNA #702 was his girlfriend and that she had borrowed money from him as well.

Former CNA #702 was terminated but continued to come and see Former Resident #80.

Staff (Former CNAs #702, #703 and #704) took Former Resident #75's bank card before he passed and used his bank card as well as one of them took his leather jacket.

She heard CNA #610 go up to Resident #18 and stated, If I show you my boobs will you give me 200 hundred dollars? She was at the local convenient store and witnessed CNA #638 sell drugs to Resident #43.

When asked how she knew it was drugs she revealed past experience know what is going on.

She revealed RN/ADON #663 had a relationship with CNA #638 so hard to report as once LPN #675 reported him for care concerns and he came up to the facility when he was off duty as RN/ADON #663 most likely told him and threatened the nurse and stated, I had to come to work to check a {explicit}.

Also, CSM #701 revealed CNA #684 was selling drugs to Residents #43 and #72.

She revealed there was intimidation, so nobody reported anything as it was an unsafe work environment.

She did not feel comfortable reporting the allegations as once she filed a grievance and was written up the next day as it was what the facility did, especially if reporting, they come after the person that reported not the person that was abusing the residents.

She did not feel comfortable going to anyone at the facility to report and was not aware how to report any other means including anonymous.g.

Interview on 05/21/26 at 9:09 A.M. with RN/ADON/Wound Nurse #663 revealed she oversaw wound care at the facility.

She had an outside wound provider come in on a weekly basis to see all wounds including pressure and surgical.

She verified FR #77 was not seen by the outside wound provider.

She confirmed there was no assessment of the surgical wound including measurements, appearance, number of retention sutures and/or anything regarding the measurement of the wound dehiscence as noted in the hospital note.

She verified the only skin assessments in his record were on 04/04/26 which did not have that he had an abdominal incision, and on 04/08/26 and 04/15/26 it had that he had an abdominal incision but no description of it.

She verified there was a treatment order on return from the hospital on [DATE] that included cleansing with saline, applying with an abdominal pad and taping with soft cloth adhesive, but it was not completed as ordered.

She verified she usually sees all wounds, completes the measurements and assessments and ensures the resident had a treatment, but it was overlooked as in her position it was just a lot to keep up with wounds and infection control.

She verified in her position she felt it was a lot to keep up with including wounds, infection control, ordering of supplies and the day-to-day oversight of operations.

This deficiency represents non-compliance investigated under Complaint Number 2991563 and is a recite to the complaint survey completed 03/25/26.

365784 05/29/2026

Washington Square Healthcare Center 202 Washington Street NW Warren, OH 44483

Review of facility policy labeled, Administering Medications, dated April 2019 revealed medications were to be administered in a safe and timely manner as prescribed.

Medications were to be administered in accordance with prescriber orders including required time frames.

Medications were to be administered within one hour of prescribed time unless otherwise specified.

The nurse administering the medication checks the label three times to verify right resident, right medication, right dose, right time, and right method. If a drug was withheld, refused or given at a time other than the scheduled time the individual administering the medication shall initial and circle the MAR space provided for that drug or dose.

Review of facility policy labeled, Charting and Documentation, dated July 2017 revealed the medical record should facilitate communication between the interdisciplinary team regarding the resident's response to care.

Documentation in the medical record would be objective, complete and accurate.

This deficiency represents non-compliance investigated under Complaint Number 2993004 and is a recite to the complaint surveys completed 03/25/26 and 04/20/26.

365784 05/29/2026

Washington Square Healthcare Center 202 Washington Street NW Warren, OH 44483

performing high contact resident care activities including dressing, bathing, transferring, providing