Winslow House Care Center

Inspectors wroteBased on observation, clinical record review, facility policy and staff and resident interviews the facility failed to appropriately transfer a resident from the bed to chair with the use of a mechanical lift in order to prevent a fall with injury for one of three residents reviewed (Resident #4). The full body lift tipped during Resident #4's transfer, and the resident sustained a bruise and skin tear. The facility reported a census of 47 residents. The facility corrected the deficient practice through past-noncompliance through the following actions: *Staff education completed 12/26/25 and 12/29/25 regarding full body lift safety *Removal of the full body mechanical lift pending inspection*Completion of weekly patient lift inspectionFindings include:1. [...]

Inspectors wroteBased on staff interview and Centers for Medicare and Medicaid Services (CMS) 2567 review, the facility failed to ensure an effective Quality Assurance Performance Improvement (QAPI) process to identify previously identified deficiencies, resulting in a repeated deficiency cited on the current survey and cited in the previous survey. The facility reported a census of 47 residents.

Inspectors wroteBased on observations, clinical review, staff and resident interviews, and facility policy review, the facility failed to complete wound treatment as ordered for 1 of 5 sampled residents (Resident #1). The facility reported a census of 47 residents. The facility corrected the deficient practice though past-noncompliance through the following actions: *All residents with active treatment orders were assessed and treatments confirmed as completed per physician order*Reeducation of all licensed nursing staff on 1/4/26 and 1/5/26*Post correction audits and weekly audits1. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had diagnoses which included heart failure, diabetes, non-Alzheimer's dementia, vascular disease and a stage 3 pressure ulcer, and received pressure ulcer/injury care. [...]

Inspectors wroteBased on observations, clinical review, staff interviews and facility policy review, the facility failed to utilize Enhanced Barrier Precaution (EBP) for 1 of 3 sampled residents reviewed (Resident #1). The facility reported a census of 47 residents. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had diagnoses which included heart failure, diabetes, non-Alzheimer's dementia, vascular disease and a stage 3 pressure ulcer (full thickness skin loss), and received pressure ulcer/injury care. The resident required substantial assistance from staff for toileting, bathing, and partial assistance for ambulation. The MDS indicated the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated the resident had severe cognitive impairment. [...]

Inspectors wroteBased on observations, clinical record review, staff interviews and facility policy review the facility failed to utilize Enhanced Barrier Precaution (EBP) for 4 out of 4 encounters with residents (Resident #3 and Resident #32) and their environment, and failed to personal protective equipment (PPE) while handling dirty laundry. The facility reported a census of 48 residents.

Inspectors wroteBased on observation, record review, interviews, and policy review the facility failed to maintain code status records for 1 of 3 residents reviewed (Resident #21). The facility was unable to locate code status documentation after a resident's return from the hospital. The facility reported a census of 48 residents.

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code all diagnoses and Preadmission Screening and Resident Review (PASRR) for 1 of 1 resident reviewed for Minimum Data Set (MDS) assessments (Resident #7). The facility reported a census of 48 residents.

Inspectors wroteBased on interview and clinical record review, the facility failed to obtain a resident's Level II Preadmission Screen and Resident Review (PASRR), failed to implement Level II requirements, and failed to resubmit the Level I after expiration for one out of one resident reviewed (Resident #7). The facility reported a census of 48 residents.

Inspectors wroteBased on observation, record review, interviews, and policy review the facility failed to provide a resident unable to carry out Activities of Daily Living (ADLs) independently the necessary services to maintain adequate personal hygiene and grooming (Resident #28). The resident was admitted to the facility 9/4/25 and was bathed/showered 1 time between 9/4/25 and 9/25/25. The facility reported a census of 48 residents.

Inspectors wroteBased on observation, record review, and staff interviews the facility failed to update as needed and provide current daily staffing information for residents and visitors. The facility reported a census of 48 residents.

Inspectors wroteBased on observation, staff and resident interviews, and facility policy and clinical record review, the facility failed to ensure an accurate inventory of medications by accounting for controlled medications that have been received, dispensed, and administered for four of four residents reviewed. (Residents #1, #5, #6, & #7). The facility reported a census of 44 residents.

Inspectors wroteBased on observation, record review, resident interviews, staff interviews, and policy review the facility failed to ensure comprehensive Care Plans were reviewed and revised in a timely manner for 2 of 12 residents reviewed. Resident #27's Care Plan lacked goals, triggers, and interventions related a diagnosis of schizophrenia. Resident #25's Care Plan lacked goals and interventions related to hearing impairment. The facility reported a census of 46 residents.

Inspectors wroteBased on observation, staff interviews, record review, and policy review the facility failed to follow professional standards of medication administration for 1 of 1 resident that required medications via gastric tube (Resident #20). Medications were given late without physician notification, an extended release tablet was crushed and Enhanced Barrier Precautions (EBP) were not followed appropriately. The facility reported a census of 46 residents.

Inspectors wroteBased on clinical record review, interview, and facility investigation review, the facility failed to maintain an environment as free as possible from hazards when wheelchair foot pedals had been omitted prior to transfer resulting in fracture injury for 1 of 3 residents reviewed for accidents (Resident #200). The facility reported a census of 45 residents.

Inspectors wroteBased on observation, record review, interview, and facility policy review the facility failed to treat 2 out of 3 residents reviewed with dignity during meals (Residents #42 and #21). The facility reported a census of 45 residents.

Inspectors wroteBased on observation, interviews, record review, and facility policy the facility failed to administer medications within the facility scheduled time frame 15 times in 15 days for 1 of 3 residents reviewed (Resident #10). The facility reported a census of 45 residents.