Wingfield Skilled Nursing and Rehabilitation Cente

Inspectors wroteBased on observation, interview, clinical record review and document review, the facility failed to ensure 1) a resident's drinking water placed on the floor was not in close proximity to a urinal holding the resident's bodily fluids for 1 of 23 sampled residents (Resident #17), 2) clean linens were kept covered during transport and delivery, 3) a Licensed Practical Nurse (LPN) cleaned a tablet splitter before and after use during medication administration, 4) hand hygiene supplies were readily available to staff and staff performed hand hygiene as required when performing wound care for 1 of 23 sampled residents (Resident #4), 5) Enhanced Barrier Precautions (EBP) were implemented appropriately for 1 of 23 sampled residents (Resident 13), and 6) Transmission-Based Precautions (TBP) were implemented according to facility policy and Centers for Disease Control and Prevention (CDC) [...]

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a resident's care plan related to oxygen administration was revised when the resident's oxygen order was discontinued for 1 of 23 sampled residents (Resident #70). This deficient practice had the potential to result in staff being unaware of the services required by the resident to reach and maintain their highest practicable level of functioning.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a resident with an ileostomy received care consistent with professional standards of practice and the resident's care plan for 1 of 23 residents (Resident #32), by not conducting and documenting a formal assessment of the residents ability to safely perform ileostomy self-care before allowing independent management of the pouch, not providing and documenting education on safe infection control, when to report problems; and, not ensuring staff provided and accurately documented ileostomy care and monitoring in accordance with physician orders and the care plan. This deficient practice had the potential to result in improper ostomy management, leakage, skin breakdown, infection, and inaccurate documentation of care.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to identify, report, and address signs and symptoms of dehydration for 1 of 23 sampled residents (Resident #13) by not ensuring staff assessed, documented, or implemented required care plan interventions and physician orders related to hydration needs. The deficient practice had the potential for worsening dehydration, electrolyte imbalance, delayed treatment, and compromised physical well being.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure the enteral nutrition was administered in accordance with physician orders and facility policy for 1 of 23 sampled residents (Resident #13). This deficient practice had the potential to place the resident at risk for aspiration and inadequate nutritional intake.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure 1) a safety sign was posted on the outside of a resident door related to oxygen (O2) therapy for 1 of 23 sampled residents (Resident #50) and 2) a resident requiring oxygen therapy was assessed timely when the resident complained of shortness of breath for 1 of 23 sampled residents (Resident #113). These deficient practices had the potential to result in improper handling of oxygen equipment increasing the risk of fire and compromising resident safety as well as the potential to result in physical and emotional distress.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure an oxygen administration was stopped and the concentrator removed from the resident's room when the physician's order for oxygen was discontinued for 1 of 23 sampled residents (Resident #70). The deficient practices had the potential to cause residents to use an unnecessary medication with possible adverse effects.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure 1) medications were secured in a locked cart and inaccessible to residents, visitors, and unauthorized staff when two medication carts and a treatment cart were left unlocked and unattended by a nurse, and 2) expired medications were removed from 1 of 2 medication carts inspected for medication storage. This deficient practice had the potential for residents, visitors, and unauthorized staff to have access to medications not prescribed or intended for the individual and for expired medications with diminished efficacy to be administered to residents.

Inspectors wroteBased on observation, interview, and document review, the facility failed to enforce its non smoking policy and failed to ensure staff refrained from smoking on facility property. The deficient practice created potential fire hazards and compromised the safety of residents, staff, and visitors.

Inspectors wroteBased on observation, document review and interview, the facility failed to ensure nursing hours were posted daily in the facility. This deficient practice had the potential to prevent residents and visitors from being informed of the total number of nursing staff and the actual hours worked each day.

Inspectors wroteBased on interview, clinical record review and document review, the facility failed to ensure a resident gave informed consent prior to the administration of a psychotropic medication for 1 of 23 sampled residents (Resident #80). This deficient practice had the potential for a resident to experience adverse side effects of a medication without deciding if the benefit to the resident was greater than the risk.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure 1) the activities care plan addressed a resident's visual impairment and the need for staff to support and assist the resident with personalized activities for 1 of 23 sampled residents (Resident #9). This deficient practice had the potential to prevent staff caring for the resident to be aware of the resident's personalized interests and how the staff could assist the resident to meet the resident's activity related goals. 2) A care plan was developed to address monitoring for a resident with bilateral lower extremity edema for 1 of 23 sampled residents (Resident #86). This deficient practice had the potential for the resident to suffer adverse health outcomes because of staff caring for the resident being unaware of the need to monitor for signs of leg swelling. [...]

Inspectors wroteBased on interview, clinical record review and document review, the facility failed to ensure a Licensed Practical Nurse (LPN) performed the duties as outlined in the State Board of Nursing Nurse Practice Act with safe medication administration when the LPN failed to check blood sugar levels prior to the administration of insulin for 1 of 23 sampled residents (Resident #212). The deficient practice had the potential to expose the resident to medication errors resulting in additional health complications.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a resident dependent upon staff for Activities of Daily Living (ADLs) had brief changes overnight for 1 of 23 sampled residents (Resident #36). This deficient practice had the potential to compromise resident hygiene, comfort, and dignity, and increase the risk of skin breakdown and infections.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a visually impaired resident received individualized activities based on the resident's preferences and goals for 1 of 23 sampled residents (Resident #9). This deficient practice had the potential to result in a resident feeling a loss of independence and negatively impact the resident's psychosocial well-being.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a resident's medication for neuropathy (a nerve condition causing pain, numbness, tingling, swelling, or muscle weakness in different parts of the body) was refilled timely to prevent the resident from missing eight doses of the medication for 1 of 23 sampled residents (Resident #9). This deficient practice had the potential to result in a resident experiencing unrelieved nerve pain the medication was prescribed to treat.

Inspectors wroteBased on interview, clinical record review, and document review the facility failed to ensure a resident's blood sugar levels were tested timely prior to the administration of insulin for a resident with type two diabetes mellitus for 1 of 23 sampled residents (Resident #212). This deficient practice had the potential to cause the resident to experience hypoglycemia or hyperglycemia symptoms related to blood sugar levels not being regulated.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a resident did not have a bottle of over-the-counter medication unsecured on the resident's bedside table when the resident did not have an order for the medication or to keep medications at the bedside for 1 of 23 sampled residents (Resident #9). This deficient practice had the potential to result in the resident self-medicating and suffering adverse reactions or medication interactions.

Inspectors wroteBased on interview, clinical record review, and document review the facility failed to protect a resident from being kicked by another resident for 1 of 8 sampled complaint and Facility Reported Incident (FRI) residents (Resident #5).

Inspectors wroteBased on interview, clinical record review, and document review the facility failed to report an allegation of abuse to the State Agency (SA) within the required timeframe.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure kitchen equipment temperature logs were completed daily and hand hygiene supplies were available for dietary staff to wash their hands at hand washing stations with the ability to affect 119 of 119 residents.

Inspectors wroteBased on clinical record review, document review and interview, the facility failed to include in the written Notice of Transfer or Discharge provided to residents for January 2024, the reason for transfer or discharge, the effective date and/or the location of the transfer or discharge for 8 of 36 discharged residents in January 2024 (Resident #3, #9, #10, #11, #12, #13, #14, and #15).

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a bed bound resident with a pressure ulcer was repositioned every two hours and assistive heal protectors were applied correctly, resulting in additional pressure ulcers for 1 of 22 sampled residents (Resident #81).

Inspectors wroteBased on interview and document review, the facility failed to ensure there were eight hours of consecutive Registered Nurse (RN) coverage for two of 30 days reviewed for staffing. This deficient practice could have allowed all 116 residents residing in the facility on the affected dates to go without proper assessments or certain cares RNs can perform.

Inspectors wroteBased on interview and document review, the facility failed to resolve the reported grievances from a resident regarding physcian order not being followed and preferred for double portions of food to be served at each meal for 1 of 22 sampled residents (Resident #169).

Inspectors wroteBased on interview, record review, and document review the facility failed to interview all persons involved in an investigation of misappropriation for 1 of 22 sampled residents (Resident #55).

Inspectors wroteBased on interview and clinical record review the facility failed to ensure the accuracy of a Minimum Data Set 3.0 (MDS) assessment for 1 of 22 sampled residents (Resident #23).

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure 1) care planned interventions for administering a resident's as needed (prn) pain medication were followed for 1 of 22 sampled residents (Resident #53), 2) a care plan related to wounds was complete and person centered for 1 of 22 sampled residents (Resident #81), and 3) a care plan related to anemia was complete and person centered for 1 of 22 sampled residents (Resident #40).

Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to ensure medications were administered prior to the expiration date for 1 of 10 residents observed during medication administration (Resident #29) and nystatin (a medicated powder) was applied by an individual with the required skills and training to administer medications for 1 of 22 sampled residents (Resident #23).

Inspectors wroteBased on clinical record review, interview, and document review the facility failed to ensure nystatin (a medicated powder) was applied by an individual with the required skills and training to administer medications for 1 of 22 sampled residents (Resident #23).

Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to ensure medications were not left unsecured in a resident's room by allowing a resident access to self-administer a medication and creating a potential accident by leaving a medication unsecured for 1 of 22 sampled residents (Resident #74).

Inspectors wroteBased on observation, clinical record review, interview, and document review the facility failed to ensure a resident's portable oxygen tank was not empty and oxygen tubing on the portable oxygen tank was changed per a physician's order for 1 of 22 sampled residents (resident #23). Findings Include: Resident #23 Resident #23 was admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy and acute respiratory failure with hypoxia. Empty Oxygen Tank A physician's order dated 09/20/23, documented to administer oxygen at 2 liters per minute (LPM) continuously via nasal cannula for shortness of breath and hypoxia. On 12/11/23 at 2:53 PM, Resident #23 was wearing a nasal cannula conected to an empty portable oxygen tank on the back of the resident's wheelchair. [...]

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure as needed (prn) pain medications were administered as ordered and non-pharmacological interventions were attempted prior to medicating a resident with a prn pain medication for 1 of 22 sampled residents (Resident #53).

Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to ensure medication was administered with an error rate of less than five percent (%). There were 37 opportunities and five medication errors. The medication error rate was 13.51%.

Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to ensure 1)unsecured medications were not left in a resident's room for 1 of 22 sampled residents (Resident #74), 2) an open date was written on a multi-dose vial in 1 of 1 sampled medication storage rooms, 3) expired medications were removed from 1 of 3 sampled medication carts, and 4) medication labels included an expiration date for 2 of 3 sampled medication carts.

Inspectors wroteBased on interview, observation, clinical record review, and document review, the facility failed to provide meals based on resident's preferences for 1 of 22 sampled residents (Resident #169).

Inspectors wroteBased on clinical record review, interview, and document review the facility failed to ensure 2 of 5 residents sampled for vaccinations (Resident #63 and #74) were screened for eligibility to receive a COVID-19 vaccine, education regarding the vaccine was provided to the resident and/or the resident representative, and the vaccine was offered and either administered or declined.

Inspectors wroteBased on clinical record review, interview and document review, the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were completed or submitted timely for the months of February, March, April, May, June, July, September, and October 2023.

Inspectors wroteBased on interview, clinical record review and document review, the facility failed to prevent neglect of a resident when medication was not administered per a physician's order resulting in death for 1 of 31 residents sampled for medication review (Resident #1) and prevent resident to resident abuse for 8 of 8 residents sampled with documented resident to resident altercations (Resident #9, #10, #11, #12, #13, and #14).

Inspectors wroteBased on interview, clinical record review and document review, the facility failed to administer significant medications per physician order resulting in death for 1 of 31 sampled residents (Resident #1).

Inspectors wroteBased on interview, clinical record review and document review, the facility failed to ensure a resident was free from misappropriation of property when a Certified Nursing Assistant (CNA) borrowed money from a resident and failed to pay the money back to the resident for 1 of 17 sampled residents (Resident #7).

Inspectors wroteBased on clinical record review, interview and document review, the facility failed to provide supervision to prevent two residents (Resident #8 and #9) from elopement from the facility.