Wingate at Silver Lake

Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to ensure three Residents (#97, #51, and #83), out of a total sample of 30 residents, received care and treatment to promote healing of a pressure ulcer. Specifically, the facility failed: 1. For Resident #97, to implement treatments from the wound consultant physician for a Stage 3 pressure ulcer (full-thickness loss of skin) on the right foot; 2. For Resident #51, to implement a treatment that included an antimicrobial wash for eight months to a Stage 4 pressure ulcer (full-thickness skin and tissue loss) on the coccyx (tailbone, area at the base of the spine); and 3. For Resident #83, to implement a treatment from the wound consultant physician for a Stage 1 pressure ulcer (intact skin with a localized area of non-blanchable erythema (redness)) on the upper back.

Inspectors wroteBased on record review and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed: 1. To implement an infection surveillance plan to identify, track, and monitor for infection; and 2. For Resident #77, to provide hand hygiene prior to meals and after the Resident handled his/her indwelling urinary catheter bag.

Inspectors wroteBased on interview and record review, the facility failed to ensure its staff obtained physician's orders for levothyroxine (a thyroid hormone medication) until 18 days after return from the hospital for one Resident (#24), out of a sample of 30 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure professional standards of practice were followed for one Resident (#32), in a sample of two closed records reviewed. Specifically, the facility failed to ensure medications were administered as ordered by the physician and laboratory (lab) work was completed as ordered.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure all drugs and biologicals were stored in a safe and secure manner as required. Specifically, the facility failed to: 1. Ensure medications, including vaccines, were stored at the correct temperature per manufacturer's recommendations; 2. Ensure one of four medication carts inspected was clean and free of loose pills and debris; and 3. Ensure multi-dose vials of medications were labeled with a date opened and a use-by date per manufacturer's guidelines.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing as being at high risk for falls, and whose comprehensive plan of care indicated that non-slip strips were to be adhered to the floor next to his/her bed, the Facility failed to ensure staff consistently implemented and followed interventions identified in his/her plan of care, when on 11/06/24, after moving Resident #1 to a different room, the non-slip strips required to help maintain his/her safety, were not immediately put in place in his/her new room next to the bed, and were not put in place until he/she experienced a fall.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was alert, oriented and frequently incontinent, the Facility failed to ensure he/she was treated in a dignified and respectful manner, when at 4:00 P.M. on 8/28/24, Certified Nurse Aide (CNA) #1 approached Resident #1 after an episode of incontinence and used degrading and insulting language while interacting with him/her.

Inspectors wroteBased on observations, interviews, and record review, for one Resident (#57) of 29 sampled residents, the facility failed to monitor the Resident's fluid intake to ensure that he/she was not exceeding the physician ordered fluid restriction while maintaining adequate hydration.

Inspectors wroteBased on staff interview and record review, the facility failed to complete performance reviews at least every 12 months for 3 of 3 Certified Nursing Assistant (CNA) files reviewed.

Inspectors wroteBased on review of the Facility Assessment and interviews, the facility failed to conduct and document a facility wide assessment that accurately reflected the resources necessary to care for its residents. Specifically, the facility failed to: 1. Identify evaluation of overall number of facility staff needed to ensure residents' needs are met every day and during emergencies; 2. Identify use of agency staff to fill licensed nurse staff positions; 3. Ensure required annual four-hour dementia training for eligible staff was completed as required; 4. Include resources that would be necessary to care for its residents when a COVID-19 outbreak may occur; 5. Include contracts, memorandums of understanding, or other agreements with third parties that provide services or equipment to the facility during both normal operations and emergencies; and 6. [...]

Inspectors wroteBased on observation, interview, policy review, and document review, the facility failed to maintain an infection prevention and control program to help prevent the potential transmission of a communicable disease when the facility was currently experiencing an outbreak of COVID-19 infections. Specifically, the facility failed to: 1. Ensure proper COVID-19 outbreak testing procedures were implemented for five of five facility staff members reviewed (Nurse #8, Nurse #9, Nurse #10, Certified Nursing Assistant (CNA) #5, and CNA #10); 2. Ensure proper COVID-19 outbreak testing procedures for 23 of 27 potentially exposed residents residing on the Pinewood Unit (affected COVID-19 unit); 3. Ensure COVID-19 testing procedures were followed per manufacturer's instructions for one of three staff members observed (CNA #10); 4. [...]

Inspectors wroteBased on staff interview and record review, the facility failed to ensure the Certified Nursing Assistants (CNA) completed the required no less than 12 hours annual education for 2 of 3 CNA's education files reviewed, and failed to complete the required four hours of dementia training for 3 of 3 CNA's education files reviewed

Inspectors wroteBased on observation and interview, the facility failed to ensure residents were provided with an environment that was free from accident hazards on one (Elmwood, secure unit) of four units in the facility. Specifically, the facility failed to ensure that potentially hazardous items were not left unsecured and easily accessible to residents with dementia.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure for one Resident (#60), out of a sample of 29 residents, that respiratory care was provided consistent with professional standards of practice.

Inspectors wroteBased on record review and interview, the facility failed to ensure that as needed (prn) orders for psychotropic medications were limited to 14 days, unless otherwise documented by the attending physician or prescribing practitioner that it was appropriate to extend beyond 14 days for 2 Residents (#7 and #95), out of a total sample of 29 residents.

Inspectors wroteBased on observations, interviews and records reviewed, for two Residents (#110 and #142), of 29 sampled residents, the facility failed to maintain medical records that were accurately documented. Specifically, the facility failed: 1. For Resident #110, to ensure the medical record accurately reflected the Resident and/or HCP's end-of-life goals and preferences; and 2. For Resident #142, to ensure nursing documented an incident of the Resident bleeding.

Inspectors wroteBased on record review, hospice contract review, and staff interview, the facility failed to ensure for one Resident (#145), out of a total sample of 29 residents, hospice services were provided in accordance with the agreement between the hospice and the facility. Specifically, the facility failed to provide ongoing documentation, and maintain a complete medical record of services to ensure prompt and effective communication and continuity of care for the Resident.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who had a Physician's Order for a pureed diet, the Facility failed to ensure he/she received adequate supervision/monitoring by nursing during meal service related to the inspection of meal trays by nursing for appropriateness of diet and food items per each resident's physician's order diet and restrictions, prior to the meal tray being delivered and served to resident, in an effort to prevent an incident of choking, when on 11/12/23, Resident #1's dinner tray included an item that did not meet his/her physician's ordered diet, however the nurse did not check the tray prior to service as required, Resident #1 consumed the item, started to choke and required the Heimlich Maneuver.

Inspectors wroteBased on observation and staff interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility 1. Failed to handle ready to eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross contamination; 2. Failed to have soap available at the hand washing station resulting in staff returning to food preparation without performing proper hand hygiene; 3. Failed to properly store frozen food items to prevent contamination in the walk in freezer; 4. Failed to maintain cleanliness in the main kitchen, including maintenance cleaning of the grease drippings from the over the stove hood and maintain clean floors; 5. [...]

Inspectors wroteBased on observations, interviews, Resident Group meeting concerns, and test tray results, the facility failed to ensure foods and beverages were prepared by methods which conserved nutritional value, flavor, appearance, palatability, and appetizing temperatures.

Inspectors wroteBased on observation, record review, and policy review, the facility failed to ensure staff developed and implemented a comprehensive, person-centered care plan for three Residents (#112, #51, and #139), out of a total sample of 28 residents. Specifically, the facility failed 1) For Resident #112, to develop a comprehensive, person-centered care plan for the care and treatment of a Foley catheter; 2) For Resident #51, to develop a comprehensive, person-centered care plan for the care and treatment of a urinary tract infection (UTI); and 3) For Resident #139, to develop a comprehensive, person-centered care plan for the care and treatment of a Foley catheter.

Inspectors wroteBased on observation, staff interview, record review, and policy review, the facility failed to ensure staff met professional standards of practice for three Residents (#51, #59, and #37), out of a total sample of 28 residents. Specifically, the facility 1.) Failed to obtain a physician's order for an alternating air pressure mattress and failed to follow the facility policy for weight monitoring for Resident #51; 2.) Failed to follow the facility's policy for weight monitoring for Resident #59; and 3.) Failed to obtain a physician's order for an alternating air pressure mattress for Resident #37.

Inspectors wroteBased on observation and interview, the facility failed to: (1) Label medications and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable; and (2) Store all drugs and biologicals in locked compartments, and permit only authorized personnel to have access.