Wyncote Care Center

Inspectors wroteBased on review of facility policy, review of clinical records, observation, and staff interviews, it was determined the facility failed to ensure that residents were free from abuse for two of 2 residents reviewed related physical and verbal abuse allegations (Resident R1, Resident R2).

Inspectors wroteBased on staff interviews, review of facility documentation and the review of clinical records, it was determined that the facility failed to ensure that a complete and through investigation was completed related to abuse allegations for 2 out of 3 residents reviewed (Resident R1 and Resident R3).

Inspectors wroteBased on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to implement enhanced barrier precautions for three of the six residents reviewed. (Resident R2, Resident R3, and Resident R4).

Inspectors wroteBased on review of the facility's infection control policies and procedures and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for 10 of 10 months (May 2025 -March 2026).

Inspectors wroteBased on a review of select facility policies and staff interviews, it was determined that the facility failed to ensure that the Infection Preventionist fulfilled the required duties and responsibilities of the position.

Inspectors wroteBased on facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure that, before offering the influenza immunization, each resident or the resident's representative received education regarding the benefits and potential side effects of the immunization for five of five records reviewed (R1, R2, R3, R4, R5).

Inspectors wroteBased on observation and interviews with staff, it was determined that the facility failed to maintain a safe, sanitary, and comfortable environment for residents in the facility, related with safe maintenance of two of two dryers.

Inspectors wroteBased on record review and interview with staff, it was determined that the facility failed to ensure that MDS (minimum data set, a federally required resident assessment completed at a specific interval) assessment was completed accurately for one of twenty-one residents reviewed. (Resident R9)

Inspectors wroteBased observation, review of clinical records, review of facility policy and interview with staff, it was determined that the facility failed to develop a person-centered care plan related to skin breakdown for two of twenty-one residents reviewed. (Resident R7 and Resident R8)

Inspectors wroteBased on observations, clinical record review, and staff interviews, it was determined that the facility failed to revise the care plan for enteral nutrition for one out of 16 residents reviewed. (Resident R26)

Inspectors wroteBased on observation, clinical record review and staff interview, it was determined that the facility failed to provided assistance with toileting for one of 21 residents reviewed. (Resident R23)

Inspectors wroteBased on the review of clinical records, facility documentation, and staff interviews, it was determined that the facility failed to protect the confidentiality of medical records for one of three records reviewed. (Resident R1) This was cited as past non-compliance. Findings Include:Review of an undated facility policy Medical Records Policy revealed that Wyncote Care Center maintains accurate and confidential medical records for all residents in compliance with federal and state regulations. The facility ensures secure storage, proper retention, and lawful release of medical records in accordance with CMS (Centers for Medicare & Medicaid Services).3. [...]

Inspectors wroteBased on interviews with staff, residents, and family members, review of clinical records, it was determined that the facility did not implement appropriate interventions to prevent and support the healing of pressure ulcers for one of four residents reviewed (Resident R1).

Inspectors wroteBased on review of clinical record, facility documentation, and interviews with staff, it was determined that the facility failed to provide care and treatment in accordance with professional standards of practice, by failing to perform weekly skin assessments as ordered by the physician for one of six residents reviewed. (Resident R1)

Inspectors wroteBased on the review of clinical record, facility investigation, policies and procedures interview with staff, it was determined that the facility failed to ensure resident environment was free of accident hazard related to providing appropriate technique during resident care which resulted in resident falling from the bed during care for one of five residents reviewed (Resident R1) Findings Include: Review of facility policy Fall Management Program dated December 17, 2024, revealed that The community will maintain systems designed and implemented to identify hazards and individual resident risk; evaluate hazards and risks; implement interventions to reduce hazards and risks; and monitor the effectiveness of measures implemented in an attempt to eliminate or reduce the risk of accidents as much as possible. [...]

Inspectors wroteBased on review of facility policy, review of clinical record, and staff interview, it was determined that the facility failed to review and revise a care plan related to feeding assistance for one of 12 residents reviewed (Resident R34). Findings Include: Review of facility policy Interdisciplinary Care Planning revised 12/16/2024 revealed it is the responsibility of each discipline to add, revise, and discontinue care plan problems, goals, and interventions as needed. Review of Resident R34's comprehensive care plan revised December 13, 2024, revealed the resident had potential for alteration in nutrition status related, but not limited to, dementia, varied meal completion, and decline in self-feeding with need for adaptive feeding devices. [...]

Inspectors wroteBased on review of clinical record, facility policy, observations, and interviews with staff, it was determined that the facility failed to exercise proper infection control techniques and wear personal protective equipment (PPE) during a dressing change for one of one resident observed (Residents R32).

Inspectors wroteBased facility policy, observation, and interviews, it was determined that facility failed to secure residents privacy relating to confidential medical records for 5 out of 42 residents reviewed. (Residents; R14, R28, R37, R11, and R1)

Inspectors wroteBased on observations of the daily meal preparation and delivery from the Food and Nutrition Department to the nursing unit for 41 of 46 residents reviewed and interviews with staff, it was determined that the facility failed to ensure that essential resident care equipment, for the food service operation was maintained in safe operating condition.

Inspectors wroteBased on clinical record reviews, interviews with staff, facility documentation, policy and procedure reviews and interviews with family members, it was determined that the facility failed to notify the resident's representative of a need to alter treatment significantly and failed to notify the resident's physician of an accident requiring physician intervention for two of 23 residents reviewed. (Residents R96 and R97)

Inspectors wroteBased on clinical record reviews, interviews with staff and review of facility documentation, it was determined that the facility failed to ensure adequate supervision and assistive devices to prevent accidents for one of two residents reviewed with falls. (Resident R97)

Inspectors wroteBased on facility policy, observation, interview with residents and staff and review of facility documentation, it was determined that the facility failed to ensure that all nursing staff possess the competencies and skill sets necessary to provide nursing and related services for three of twenty nine residents reviewed relating staff response to call bells, resident needs and nursing required skills. (Resident R16, Resident R39 and Resident R149)

Inspectors wroteBased on observations, review of facility policy, review of facility documentation and review of temperature logs and interviews with dietary staff, it was determined that foods were not being served to residents at temperatures that were appetizing on one of one nursing units. (Second Floor)