Wynhoven Community Care Center

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure staff completed quarterly assessments within the required timeframes for 3 (Resident #1, Resident #23, Resident #88) of 3 sampled residents reviewed for resident assessment requirements.

Inspectors wroteBased on interviews, observations, and record reviews, the facility failed to ensure a resident's enabler bar was not an accident hazard for 1 (Resident #1) of 3 sampled residents reviewed for accident hazards. This deficient practice resulted in actual harm on 02/28/2026 at 7:33PM for Resident #1, when S3Certified Nursing Assistant (CNA) transferred Resident #1 from her wheelchair to the bed. Resident #1's left leg hit the enabler bar, with a missing end cap, which resulted in a laceration to Resident #1's left lower leg. Resident #1 was then transported to a local Emergency Department (ED) where she was assessed as having a large stellate (a star-shaped or irregular, multi-angled tear in the skin) laceration to the left lower leg, received 6 interior sutures, 27 exterior sutures, a tetanus shot, and pain medication. Resident #1 required daily wound care and 14 days of antibiotics. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure an effective system was in place to ensure the resident record accurately reflected a resident's wishes for a code status of Do Not Resuscitate (DNR) if an emergency occurred for 1 (Resident #103) of 46 (Resident #1, Resident #4, Resident #5, Resident #10, Resident #11, Resident #14, Resident #19, Resident #20, Resident #23, Resident #24, Resident #25, Resident #28, Resident #29, Resident #33, Resident #35, Resident #36, Resident #37, Resident #39, Resident #40, Resident #41, Resident #46, Resident #52, Resident #53, Resident #60, Resident #61, Resident #68, Resident #71, Resident #72, Resident #76, Resident #77, Resident #80, Resident #82, Resident #83, Resident #85, Resident #86, Resident #87, Resident #88, Resident #92, Resident #93, Resident #94, Resident #97, Resident #99, Resident #102, Resident #103, Resident [...]

Inspectors wroteBased on interview and record reviews, the facility failed to implement their controlled substance policy to ensure controlled drugs were reconciled for 1 (Medication Cart b) of 3 (Medication Cart a, Medication Cart b, Medication Cart c) medication carts reviewed for reconciliation of controlled substances.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure staff wore proper personal protective equipment (PPE) for a resident on Enhanced Barrier Precautions (EBP) during a resident transfer and linen change for 3 (S10Certified Nursing Assistant [CNA], S11CNA, S12CNA) of 4 (S10CNA, S11CNA, S12CNA, S15CNA) CNAs observed while providing care to residents on EBP.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to assess a resident for self-administration of medications for 1 (Resident #29) of 1 (Resident #29) sampled residents observed with medications left at the bed side for self-administration.

Inspectors wroteBased on observations and interviews, the facility failed to ensure facility whirlpool rooms were maintained in a sanitary manner for 3 (Whirlpool Room a, Whirlpool Room b, Whirlpool Room c) of 3 (Whirlpool Room a, Whirlpool Room b, Whirlpool Room c) whirlpool rooms observed for cleanliness. Observation on 04/16/2025 at 10:30AM, of Whirlpool Room a, revealed there was an unidentified pink residue noted on the bottom of the whirlpool bathtub. Observation on 04/16/2025 at 10:45AM, of Whirlpool Room c, revealed there was an unidentified yellow residue and a piece of used paper noted on the bottom of the whirlpool bathtub. Observation on 04/16/2025 at 11:00AM, of Whirlpool Room b, revealed there was an unidentified pink residue noted on the bottom of the whirlpool bathtub. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to communicate and/or document the required information when a resident was transferred to the hospital for 1 (Resident #103) of 3 (Resident #83, Resident #102, Resident #103) sampled residents reviewed for transfer requirements.

Inspectors wroteBased on interview, and record reviews the facility failed to develop a person-centered care plan for a resident with a Urinary Tract Infection (UTI) receiving Intravenous (IV) Antibiotics via a Midline Intravenous Catheter. This deficient practice was identified for 1 (Resident #46) of 1 (Resident #46) residents investigated for intravenous antibiotic usage.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure a resident's care plan was revised to update his code status (a term used to describe what type of interventions, if any, a healthcare team could perform if an individual's heart stopped beating or they stopped breathing). This deficient practice was identified for 1 (Resident #103) of 23 (Resident #5, Resident #23, Resident #25, Resident #29, Resident #33, Resident #35, Resident #39, Resident #40, Resident #41, Resident #46, Resident #68, Resident #71, Resident #72, Resident #76, Resident #80, Resident #82, Resident # 83, Resident #92, Resident #93, Resident #94, Resident #99, Resident #102, and Resident #103) sampled residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a Registered Nurse adhered to professional standards of practice when a Registered Nurse (S6Interim Clinical Care Coordinator [S6ICCC]) falsified a resident's medical record. This deficient practice was identified for 1 (S6ICCC) of 2 (S6ICCC, and S7Quality Management Nurse) Registered Nurses identified as having revised Resident #103's care plan.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a resident's pressure ulcer treatment plan was carried out in accordance with physician's orders for 1 (Resident #94) of 2 (Resident #94, Resident #99) sampled residents investigated for pressure ulcer care.

Inspectors wroteBased observations, interviews, and record reviews, the facility failed to: 1. Ensure the facility's infectious waste storage room was locked and not accessible to residents prone to wandering for 1 (Storage Room a) of 1 (Storage Room a) infectious waste storage rooms observed; 2. Ensure disposable razors were not accessible for 2 (Shower Room a, Shower Room b) of 3 (Shower Room a, Shower Room b, Shower Room c) observed; and, 3. Ensure shower rooms were secured for 3 (Shower Room a, Shower Room b, and Shower Room c) of 3 (Shower Room a, Shower Room b, Shower Room c) shower rooms observed; and, 4. Ensure whirlpool rooms were secured for 3 (Whirlpool Room a, Whirlpool Room b, Whirlpool Room c) of 3 (Whirlpool Room a, Whirlpool Room b, Whirlpool Room c) whirlpool rooms observed.

Inspectors wroteBased on interview and record reviews, the facility failed to maintain an accurate medical record for a resident's code status (a term used to describe what type of interventions, if any, a healthcare team could perform if an individual's heart stopped beating or they stopped breathing). This deficient practice was identified for 1 (Resident #103) of 23 (Resident #5, Resident #23, Resident #25, Resident #29, Resident #33, Resident #35, Resident #39, Resident #40, Resident #41, Resident #46, Resident #68, Resident #71, Resident #72, Resident #76, Resident #80, Resident #82, Resident #83, Resident #92, Resident #93, Resident #94, Resident #99, Resident #102, and Resident #103) sampled residents reviewed for accurate records.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident was referred for dental services within 3 days of a resident's dentures being missing for 1 (Resident #1) of 1 (Resident #1) sampled residents with missing dentures in a total sample of 3.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to ensure a resident who no longer resided on a locked memory care unit's careplan was updated for 2 (Resident #9 and Resident #71) of 2 residents reviewed for Dementia Care.

Inspectors wroteBased on record review and interview, the facility failed to obtain the resident's most recent documentation of services provided for 2 (Resident #53 and Resident #104) of 2 (Resident #53 and Resident #104) sampled residents reviewed for hospice.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to ensure a resident's pain level was reassessed and managed for 1(Resident #40) of 1(Resident #40) residents reviewed for pain management.