Winder Center for Nursing and Healing

Inspectors wroteBased on interviews, record review, and a review of the facility policies titled Transfer and Discharge [including Against Medical Advice (AMA)] and Bed Hold Prior to Transfer, the facility failed to provide residents and their Resident Representatives (RR) with the required written transfer and bed-hold notices following emergent hospital transfers for four of four sampled residents (R) (R93, R10, R155, and R34). This failure limited residents' and representatives' ability to understand appeal rights and access Ombudsman information, placing all residents at risk for potential denial of readmission and loss of their residence after hospitalization.

Inspectors wroteBased on observations, interviews, and a review of the facility policy titled Sanitation, the facility failed to ensure kitchen staff thoroughly cleaned and air-dried pots, pans, and food service equipment before storage. This failure increased the potential risk of foodborne illness and had the potential to affect 143 of the 146 residents receiving dietary services.

Inspectors wroteBased on observations, interviews, and a review of the facility's policy titled Food-Related Garbage & Rubbish Removal, the facility failed to ensure proper disposal and containment of waste in two of the two dumpsters. This failure had the potential to affect all 146 residents, as well as visitors and staff, and increased the risk of attracting pests.

Inspectors wroteBased on document review, interviews, and a review of the facility's policy titled Antibiotic Stewardship Program, the facility failed to ensure antibiotics were prescribed only when a diagnosed infection was present for eight of 12 months of antibiotic stewardship reviewed. This failure had the potential to affect all residents in the facility and to increase the risk of adverse events, including the development of antibiotic-resistant organisms, due to unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on interviews, record review, and a review of the facility policy titled Resident Assessment- Coordination with PASRR Program, the facility failed to complete a Level II pre-admission screening and resident review (PASARR) evaluation after a resident received a post-admission mental illness diagnosis for one of 32 sampled residents (R) (R41). This deficient practice could lead to residents not receiving necessary services.

Inspectors wroteBased on observations, interviews, record review, and review of the facility's policy titled Food Preparation and Service, the facility failed to ensure residents were served food that was palatable to four of 32 sampled residents (R) (R131, R93, R160, and R48).

Inspectors wroteBased on observations, interviews, record review, and a review of the facility's policy titled Handwashing/Hand Hygiene, the facility failed to ensure hand hygiene was performed following the administration of inhaled medication for one of six residents (R) (R53) observed during medication administration. The failure to perform proper hand hygiene created a risk for bacterial contamination of medication cart supplies and increased the potential for infection transmission.

Inspectors wroteBased on record review, interviews, and a review of the facility's policy titled Pneumococcal Vaccine (Series), the facility failed to ensure that one of five residents (R) (R41) was offered and administered pneumococcal vaccinations in accordance with nationally recognized standards. Specifically, the facility failed to offer or administer the appropriate pneumococcal vaccine to R41, who was eligible to receive either Prevnar 20 (PCV20) or PCV15 one year after receiving Pneumovax 23 (PPSV23). Additionally, the facility failed to obtain a complete vaccination history, provide education regarding the pneumococcal vaccine, and secure a signed consent indicating refusal of the vaccine for a resident (R58). These failures had the potential to increase residents' risk of contracting pneumonia.

Inspectors wroteBased on record review, interviews, and a review of the facility's policy titled COVID-19 Vaccination, the facility failed to ensure that one of five residents (R) (R58) reviewed for Coronavirus disease 2019 (COVID-19) immunization received education regarding the risks and benefits of the COVID-19 vaccine/booster before declining vaccination.

Inspectors wroteBased on record review, review of facility policy titled Care Plan, Comprehensive Person-Centered, and staff interviews, the facility failed to follow the care plan for skin assessments for one resident (R) (R145) of six residents reviewed for pressure ulcers. On 10/10/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator, Regional Director of Operations, Regional Director of Clinical Operations, and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 10/10/2024 at 10:53 am. The noncompliance related to the IJ was identified to have existed on 2/16/2024. An Acceptable IJ Removal Plan was received on 10/11/2024. [...]

Inspectors wroteBased on observations, record review, review of facility policy titled Pressure Injury Prevention and Management, and staff interviews, the facility failed to provide the necessary care and services to prevent the development and worsening of pressure ulcers for one of six residents (R) (R145) reviewed for pressure ulcers. Specifically, the facility failed to ensure weekly skin assessments and wound observations were completed for R145 and failed to provide the recommended treatment for a sacral pressure ulcer. On 10/10/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. [...]

Inspectors wroteBased on record review and resident and staff interviews, the facility failed to ensure the advanced directive was documented accurately throughout the Electronic Medical Record (EMR) for one resident (R) (R397) of 40 residents reviewed for advanced directive.

Inspectors wroteBased on record review and staff interviews, the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) (Form CMS-10123), and facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) Form CMS-100550) to two of three residents (R) (R94 and R397) reviewed that were discharged from Medicare Part A coverage.

Inspectors wroteBased on closed records review, interviews, and review of facility policy titled Blood Glucose Monitoring, the facility failed to ensure professional standards were followed for blood sugar monitoring of one resident receiving insulin of seven residents (R) (R146) reviewed for unnecessary medications.

Inspectors wroteBased on staff/resident interviews, record review and review of the facility policy titled Ostomy Care-Colostomy, Urostomy and Ileostomy, the facility failed to obtain a physician order for colostomy care for one of one resident (R) (R396) who required colostomy services.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to maintain sanitary conditions of the kitchen equipment including the ice maker, interior sides of the beverage cooler, mixer, two deep fryers, knifes, and the floors and walls of the dry storage area. In addition, the facility failed to label and date items in an upright cooler. The census was 100 residents, and the sample size was 33.

Inspectors wroteBased on observations, staff interviews, record review, and policy review, the facility failed to ensure resident's dignity was maintained by not displaying confidential clinical information indicating clinical status or care needs for two residents' (R) (R#51 and #24) openly posted in the resident's room. The sample size was 38.