Inspection visit
Health inspection
6 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0623
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings include:
1. Review of Resident #39's medical record revealed the resident was admitted to the facility on [DATE] with
diagnoses of Parkinson's disease, hypertension and low back pain. Review of Resident #39's Minimum
Data Set (MDS) 3.0 assessment dated [DATE] confirmed the resident exhibited moderate cognitive
impairment.
Review of Resident #39's progress notes from [DATE] to [DATE] revealed the resident was transferred to
the hospital and admitted on [DATE] and returned to the facility on [DATE] with a diagnosis of urinary tract
infection. The resident was transferred to the hospital and admitted on [DATE] and returned to the facility on
[DATE] with a diagnosis of gastrointestinal hemorrhage.
Interview on [DATE] at 9:46 A.M. with the Director of Nursing (DON) confirmed the social worker was out on
leave, and Resident #39 and/or the resident's representative did not receive notification in writing the
reason for the discharge to the hospital in an easily understood language on both [DATE] and [DATE] as
required.
2. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with
diagnoses including chronic respiratory failure, morbid obesity and heart failure. Resident #51 was
discharged to the hospital on [DATE] and expired while out of the facility. The face sheet listed her son as
the responsible party. There was no evidence in the chart that the responsible party was notified in writing
of the reason for transfer to the hospital.
Interview was conducted on [DATE] at 8:26 A.M. with the Administrator who verified the facility had not
been notifying responsible parties in writing of resident transfers to the hospital but did implement the
written notification system on [DATE] after reviewing it with a surveyor. The Administrator said they will
notify the responsible party using certified mail to keep a record of it on each resident.
3. Review of the medical record revealed Resident #45 was admitted to the facility on [DATE] with
diagnoses including stroke, dysphagia and asthma. Resident #45 was discharged to the hospital on
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 9
Event ID:
365784
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365784
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/14/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Washington Square Healthcare Center
202 Washington Street NW
Warren, OH 44483
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0623
Level of Harm - Potential for
minimal harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
[DATE] due to shortness of breath and returned to the facility on [DATE] with additional diagnoses of
congestive heart failure with pleural effusions, oropharyngeal dysphagia and aspiration pneumonia. The
face sheet listed his daughter as the responsible party. There was no evidence in the chart that the
responsible party was notified in writing of the reason for transfer to the hospital.
Interview was conducted on [DATE] at 8:26 A.M. with the Administrator who verified the facility had not
been notifying responsible parties in writing of resident transfers to the hospital but did implement the
written notification system on [DATE] after reviewing it with a surveyor. The Administrator said they will
notify the responsible party using certified mail to keep a record of it on each resident.
Event ID:
Facility ID:
365784
If continuation sheet
Page 2 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365784
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/14/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Washington Square Healthcare Center
202 Washington Street NW
Warren, OH 44483
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0625
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Notify the resident or the resident’s representative in writing how long the nursing home will hold the
resident’s bed in cases of transfer to a hospital or therapeutic leave.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings include:
1. Review of Resident #39's medical record revealed the resident was admitted to the facility on [DATE] with
diagnoses of Parkinson's disease, hypertension and low back pain. Review of Resident #39's Minimum
Data Set (MDS) 3.0 assessment dated [DATE] confirmed the resident exhibited moderate cognitive
impairment.
Review of Resident #39's progress notes from [DATE] to [DATE] revealed the resident was transferred to
the hospital and admitted on [DATE] and returned to the facility on [DATE] with a diagnosis of urinary tract
infection. The resident was transferred to the hospital and admitted on [DATE] and returned to the facility on
[DATE] with a diagnosis of gastrointestinal hemorrhage.
Interview on [DATE] at 9:46 A.M. with the Director of Nursing (DON) confirmed the social worker was out on
leave, and Resident #39 and/or the resident's representative did not receive notification of the bed-hold
policy and reserve bed payment at the time of transfer to the hospital on both [DATE] and [DATE] or within
twenty-four hours of transfer to the hospital as required.
2. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with
diagnoses including chronic respiratory failure, morbid obesity and heart failure. Resident #51 was
discharged to the hospital on [DATE] and expired while out of the facility. The face sheet listed her son as
the responsible party. There was no evidence in the chart that the responsible party was notified in writing
of the bed-hold policy upon transfer to the hospital.
Interview was conducted on [DATE] at 8:26 A.M. with the Administrator who verified the facility had not
been notifying responsible parties in writing of bed-hold information until [DATE] after reviewing it with a
surveyor. The Administrator said they will notify the responsible party using certified mail to keep a record of
it on each resident.
3. Review of the medical record revealed Resident #45 was admitted to the facility on [DATE] with
diagnoses including stroke, dysphagia and asthma. Resident #45 was discharged to the hospital on [DATE]
due to shortness of breath and returned to the facility on [DATE] with additional diagnoses of congestive
heart failure with pleural effusions, oropharyngeal dysphagia and aspiration pneumonia. The face sheet
listed his daughter as the responsible party. There was no evidence in the chart that the responsible party
was notified in writing of the bed-hold policy.
Interview was conducted on [DATE] at 8:26 A.M. with the Administrator who verified the facility had not
been providing written bed-hold notice to the resident or responsible party upon discharge to the hospital.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365784
If continuation sheet
Page 3 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365784
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/14/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Washington Square Healthcare Center
202 Washington Street NW
Warren, OH 44483
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Residents Affected - Few
Findings include:
1. Review of Resident #39's medical record revealed the resident was admitted to the facility on [DATE] with
diagnoses including supranuclear palsy, Parkinson's disease and chronic low back pain. Review of
Resident #39's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited
moderate cognitive impairment was on hospice services and was not coded for a life expectancy of less
than six months.
Review of Resident #39's physician order dated 10/15/19 indicated to admit the resident to hospice
services with a diagnosis of supranuclear palsy, and the resident's prognosis was six months or less
provided the disease followed its expected progression.
Interview on 11/13/19 at 8:22 A.M. with Registered Nurse (RN) #801 confirmed Resident #39's
comprehensive assessment dated [DATE] did not accurately reflect the resident's hospice diagnosis with a
life expectancy of six months or less.
2 Review of Resident #48's medical record revealed the resident was admitted to the facility on [DATE] with
diagnoses including post-traumatic stress disorder, chronic obstructive pulmonary disease and
schizophrenia. Review of Resident #48's MDS 3.0 assessment dated [DATE] revealed the resident
exhibited intact cognition, received seven doses of an antipsychotic, seven doses of an anticoagulant and
seven doses of a diuretic during the seven-day assessment reference period.
Review of Resident #48's physician orders revealed an order dated 10/17/19 for Risperdal (antipsychotic)
0.5 mg (milligrams) at bedtime, an order dated 10/17/19 for xarelto (anticoagulant) 20 mg daily with
breakfast and an order dated 10/18/19 for Lasix (diuretic) 40 mg daily.
Review of Resident #48's medication administration records from 10/18/19 to 10/24/19 revealed the
resident received six days of the antipsychotic, six days of the anticoagulant and six days of the diuretic.
Interview on 11/13/19 at 10:21 A.M. with RN #801 confirmed Resident #48's comprehensive assessment
dated [DATE] did not accurately reflect the resident's medication administration for the resident's use of an
anticoagulant, antipsychotic or diuretic.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365784
If continuation sheet
Page 4 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365784
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/14/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Washington Square Healthcare Center
202 Washington Street NW
Warren, OH 44483
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings include:
Review of medical record revealed Resident #30 had an admission date 08/18/16 with diagnoses of
multiple sclerosis, constipation, quadriplegia, adult failure to thrive, reduced mobility, and supraventricular
tachycardia.
Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #30 revealed she
had impaired cognition and was totally dependent of two people with bed mobility and toileting. Transfers
and locomotion did not occur.
Review of care plan dated 08/18/16 for Resident #30 revealed she was at risk for impaired bowel
elimination related to history of constipation. Interventions included; monitor bowel movements daily,
monitor for bloating, lower abdominal pain, fecal impaction and report signs and symptoms of fecal
impaction, and give medications as ordered to enhance bowel elimination.
Review of form labeled, Bowel Protocol dated 01/08/14 per Medical Director/ Primary Care Physician #806
revealed if a resident had no bowel movement in three days per the bowel monitoring records, the following
standing orders were to be followed by the nurse:
•
Step 1- give prune juice, if no results in 24 hours;
•
Step 2- give 30 milliliters of milk of magnesia (laxative) by mouth, if no results in 24 hours;
•
Step 3- give Dulcolax suppository (laxative), if no results in 24 hours;
•
Step 4- give fleets enema, obtain order from physician, if no results then notify the physician again.
The nurse was to chart the interventions and monitor results. The orders may change pending on the
physician. The Medical Director/ Primary Care Physician #806 signed the standing orders for Resident #30
on 01/08/14, and this form was in Resident #30's medical chart.
Review of form labeled, Monthly Bowel Movement Record for August 2019 revealed Resident #30 did not
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365784
If continuation sheet
Page 5 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365784
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/14/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Washington Square Healthcare Center
202 Washington Street NW
Warren, OH 44483
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
have a bowel movement on 08/01/19, 08/02/19, 08/03/19, 08/04/19 and 08/05/19. She did not have a bowel
movement on 08/14/19, 08/15/19, 08/16/19 and 08/17/19. She did not have a bowel movement on 08/30/19
and 08/31/19.
Review of August 2019 and September 2019 Medication Administration Record (MAR) for Resident #30
revealed she did not receive any standing orders per the bowel protocol.
Review of nursing notes for August 2019 and September 2019 revealed no documentation regarding
Resident #30 not having bowel movements, did not have bowel assessments completed by the nurse
checking for constipation and no documentation of interventions that were initiated because of no bowel
movements.
Review of form labeled, Monthly Bowel Movement Record for September 2019 revealed Resident #30 did
not have a bowel movement on 09/01/19, 09/02/19, 09/03/19, 09/04/19, 09/05/19 and 09/06/19. She did not
have a bowel movement on 09/24/19, 09/25/19, 09/26/19 and 09/27/19.
Review of current physician orders for November 2019 revealed Resident #30 was to have nothing by
mouth and received her medications per her peg tube.
Interview on 11/13/19 at 2:29 P.M. with Registered Nurse (RN) Supervisor #807 revealed the night shift
nurse was to check the bowel movement record every night and initiate the bowel protocol per the facility
standing orders. She revealed the Medical Director/ Primary Care Physician (PCP) #807 had ordered
Resident #30 to follow the bowel protocol in her chart.
Interview on 11/13/19 at 2:49 P.M. with the Director of Nursing verified Resident #30 did not have a bowel
movement from 08/01/19 through 08/05/19 (five days), from 08/14/19 through 08/17/19 (four days), from
08/30/19 through 09/06/19 (eight days), and from 09/24/19 through 09/27/19 (four days). She verified the
nurse did not initiate the bowel protocol as ordered per her Medical Director/ PCP #807. She verified the
nurses did not document Resident #30's lack of bowel movement, abdominal assessments, and
interventions they had implemented because of no bowel movement. She verified the bowel protocol was
ordered for all the residents at the facility and was not individualized for Resident #30 as she was not to
have nothing by mouth and her medications were to be administered per her peg tube.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365784
If continuation sheet
Page 6 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365784
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/14/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Washington Square Healthcare Center
202 Washington Street NW
Warren, OH 44483
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
Based 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.
Residents Affected - Few
Findings include:
Review of Resident #21's medical record revealed an admission date of 07/16/19 with diagnoses including
chronic obstructive pulmonary disease (COPD), acute cholecystitis, protein calorie malnutrition, benign
prostatic hyperplasia (BPH) and a pacemaker.
Review of Resident #21's physician orders revealed an order dated 07/17/19 for oxygen to be administered
at four liters per minute via nasal cannula.
Review of Resident #21's respiratory care plan revealed an intervention dated 07/29/19 for staff to
administer oxygen as ordered by the physician.
Observation on 11/12/19 at 10:04 A.M. revealed Resident #21 sitting in a recliner in his room wearing a
nasal cannula, and the dial on the oxygen concentrator was infusing at 2.5 liters per minute.
Interview on 11/12/19 at 10:08 A.M. with Licensed Practical Nurse (LPN) #802 confirmed Resident #21's
oxygen was not infusing as indicated in the physician orders, and the nurse corrected the rate flow to four
liters as ordered.
Observation on 11/13/19 at 2:14 P.M. revealed Resident #21 was sitting in a specialized chair in his room
wearing an oxygen nasal cannula with a liquid oxygen tank secured to the back of the specialized chair
infusing at three liters per minute.
Interview on 11/13/19 at 2:15 P.M. with LPN #803 confirmed the physician order was to administer oxygen
at four liters per minute via nasal cannula for Resident #21, and the oxygen was infusing at three liters per
minute per nasal cannula. LPN #803 confirmed the State Tested Nursing Assistant (STNA) filled up the
liquid oxygen tank at 12:00 P.M. and put Resident #21 in the specialized chair, placed the nasal cannula on
the resident, placed the liquid oxygen tank on the back of the specialized chair, dialed up the rate flow of
three liters, disconnected the oxygen tubing from the room oxygen concentrator and connected the tubing
to the resident prior to taking the resident to the dining room. LPN #803 also confirmed the resident's rate
flow rate which was placed on the resident by the STNA was inaccurate.
Interview on 11/14/19 at 12:30 P.M. with Registered Nurse (RN) #801 confirmed the facility had four
additional residents (Residents #16, #37, #45, and #50) who required oxygen therapy.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365784
If continuation sheet
Page 7 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365784
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/14/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Washington Square Healthcare Center
202 Washington Street NW
Warren, OH 44483
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0839
Employ staff that are licensed, certified, or registered in accordance with state laws.
Level of Harm - Minimal harm
or potential for actual harm
Based 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.
Residents Affected - Few
Findings include:
Review of Resident #21's medical record revealed an admission date of 07/16/19 with diagnoses including
chronic obstructive pulmonary disease (COPD), acute cholecystitis, protein calorie malnutrition, benign
prostatic hyperplasia (BPH) and a pacemaker.
Review of Resident #21's physician orders revealed an order dated 07/17/19 for oxygen to be administered
at four liters via minute by nasal cannula.
Review of Resident #21's respiratory care plan revealed an intervention dated 07/29/19 for staff to
administer oxygen as ordered by the physician.
Observation on 11/13/19 at 2:14 P.M. revealed Resident #21 was sitting in a specialized chair in his room
wearing an oxygen nasal cannula with a liquid oxygen tank secured to the back of the specialized chair
infusing at three liters per minute.
Interview on 11/13/19 at 2:15 P.M. with Licensed Practical Nurse (LPN) #803 confirmed the physician order
was to administer oxygen at four liters per minute via nasal cannula for Resident #21, and the oxygen was
infusing at three liters per minute per nasal cannula. LPN #803 confirmed the STNA filled up the liquid
oxygen tank at 12:00 P.M. and put Resident #21 in a specialized chair, placed the nasal cannula on the
resident, placed the liquid oxygen tank on the back of the specialized chair, dialed up the rate flow of three
liters, disconnected the oxygen tubing from the room oxygen concentrator and connected the tubing to the
resident prior to taking the resident to the dining room. LPN #803 also confirmed the resident's oxygen rate
flow rate which was placed on the resident by the STNA was inaccurate.
Interview on 11/14/19 at 10:37 A.M. with Ohio Nurse Aide Training Program Coordinator (ONATPC) #804
revealed STNAs were taught oxygen was considered a medication, and they were not to regulate flow rates
for the residents. Regulation of oxygen therapy was not within the STNA's scope of practice.
Interview on 11/14/19 at 10:45 A.M. with Director of Nursing (DON) confirmed that STNAs were allowed to
regulate oxygen for the residents, and she was unaware the STNAs were not allowed to regulate or adjust
the flow rate for residents including Resident #21's oxygen administration.
Interview on 11/14/19 at 11:45 A.M. with STNA #805 verified that she was allowed to regulate the oxygen
flow rate for residents in the facility, and she regulated the oxygen flow rate for Resident #21. STNA #805
indicated the procedure she followed was to take the oxygen tubing off the concentrator in the room and to
re-attach the tubing to the temporary tank that was used to transport the resident. STNA #805 would adjust
the flow rate according to the rate the nurse informed the STNA that it should be.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365784
If continuation sheet
Page 8 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365784
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/14/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Washington Square Healthcare Center
202 Washington Street NW
Warren, OH 44483
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0839
Interview on 11/14/19 at 12:30 P.M. with Registered Nurse (RN) #801 confirmed the facility had four
additional residents (Residents #16, #37, #45, and #50) who required oxygen therapy.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365784
If continuation sheet
Page 9 of 9
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Back to topCitations
6 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F625 - Transfer and discharge-
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F839 - Staff qualifications
Employ staff that are licensed, certified, or registered in accordance with state laws.
FAQ · About this visit
Common questions about this visit
What happened during the November 14, 2019 survey of WASHINGTON SQUARE HEALTHCARE CENTER?
This was a inspection survey of WASHINGTON SQUARE HEALTHCARE CENTER on November 14, 2019. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at WASHINGTON SQUARE HEALTHCARE CENTER on November 14, 2019?
Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide safe and appropriate respiratory care for a resident when needed."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.