Wynwood Rehabilitation and Healthcare Center

Inspectors wroteBased on observation, interview and review of facility documents it was determined that the facility failed to provide a safe, clean, and comfortable environment in resident rooms and designated facility utility areas. The deficient practice was identified on 2 of 3 units. The deficient practice was evidenced by the following: On 12/01/2025 at 1:14 PM while in Resident # 89's room, the surveyor observed linens on the floor and a pile of debris that appeared to be swept but was left and not discarded. On 12/02/2025 at 12:17 PM, in the Soiled Utility room near room [ROOM NUMBER], the surveyor observed filled trash bags left on the floor in the room and not in the container. On the same date at 12:26 PM, the surveyor observed a linen cart outside of room [ROOM NUMBER] with personal bags, including a purse, on the top shelf among the clean linens and incontinence briefs. On 12/04/2025 at 11: [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete the Comprehensive Minimum Data Set (MDS), a periodic and federally mandated, standardized assessment tool, within the required time frame. This deficient practice was identified for 2 of 11 residents (Residents #30 and Resident #40) reviewed for Resident Assessment and was evidenced by the following: Reference: The Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual classified the Observation (Look Back) Period as the time period over which the resident's condition or status was to be captured by the MDS. The Assessment Reference Date (ARD) referred to the last day of the observation (or look back) period that the assessment covered for the resident. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete the Quarterly Minimum Data Set (QMDS), a periodic and federally mandated, standardized assessment tool, within the required time frame. This deficient practice was identified for 1 of 11 residents (Resident #4) reviewed for Resident Assessment and was evidenced by the following: Reference: The Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual classified the Observation (Look Back) Period as the time period over which the resident's condition or status was to be captured by the MDS. The Assessment Reference Date (ARD) referred to the last day of the observation (or look back) period that the assessment covered for the resident. The Quarterly assessment was considered timely if 1). [...]

Inspectors wroteBased on observation, interview, and review of medical records and other facility documentation, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS) for 2 of 32 residents reviewed, Resident #8 and Resident #51. This deficient practice was evidenced by the following:A review of the admission Record for Resident #8 which reflected that the resident was admitted with diagnoses that included Schizophrenia and Depression. A review of the level II Preadmission Screening and Resident Review (PASRR) revealed Resident #8 was positive for a mental illness. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure that medications for a discharged resident were properly removed from the medication storage area. The deficient practice was identified for 1 of 3 medication carts inspected during the Medication Storage and Labeling task. The deficient practice was evidenced by the following: On 12/02/2025 at 12:48 PM, the surveyor inspected Medication Cart 1 located outside of room [ROOM NUMBER]. At that time, in the presence of Licensed Practical Nursing # 1 (LPN # 1), the surveyor discovered a medication card for Gabapentin 100 milligram capsules located behind the bottom drawer of the cart. The medication card contained 16 remaining capsules and belonged to a resident who had been previously discharged from the facility. [...]

Inspectors wroteComplaint # 408484Based on observation, interview and record review, the facility failed to ensure resident records were accurate and complete for 1 of 3 residents (Resident # 9 reviewed for activities of daily living (ADL) care, specifically related to shower documentation. The deficient practice was evidenced by the following:A review of Resident #9's medication administration record (MAR) for the month of November 2025 revealed that nurses had documented that Resident #9 received showers on the following dates:11/04/202511/07/202511/11/202511/14/202511/18/202511/21/202511/25/202511/28/2025 A review of Resident # 9's documentation survey report for the month of November 2025 revealed that the Certified Nursing Assistants (CNA), had documented that Resident # 9 had refused a shower on 11/04/2025. The CNA's documented that Resident # 9 received showers on 11/18/2025 and 11/21/2025. [...]

Inspectors wroteBased on observation, and interview the facility failed to ensure resident beds and mattress were properly positioned and adjusted to meet residents' needs and ensure safety and comfort foe 1 of 2 residents (Resident # 118) observed for positioning. The deficient practice was evidenced by the following: During initial tour on 12/01/2025 at 10:04 AM the surveyor observed Resident #118 in bed with their feet extended over the mattress and their ankles resting on the foot board. Resident #118 stated he/she can't sleep at night because his/her feet are always hanging off the bed. Resident #118 said he/she thinks the told a nurse about the bed being too small. A review of Resident # 118 admission Minimum Data Set (MDS) dated [DATE] revealed under section C that Resident # 118 had a BIMS score of 14 indicating intact cognition. [...]

Inspectors wroteBased on observations on 12/02/2025 in the presence of the facility's Maintenance Assistant (MA), it was determined that the facility failed to provide hand rails on both sides of the corridor. This deficient practice had the potential to affect all 104 Residents in the facility. Observation on 12/02/2025 the surveyor observed, measured and recorded a six foot- nine inch (6'-9) section of wall in the South wing adjacent to the Physical Therapy area with no evidence of a hand rail for Residents to use. The MA confirmed the finding at the time of observation. The Administrator and MA were informed of the Life Safety Code deficiency during the survey exit at approximately 1:30 PM.NJAC 8:39-31.4 (a).

Inspectors wroteBased on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to have a system in place to ensure a consistent and safe smoking process for 17 residents who were identified as smokers by failing to ensure a) provision of adequate and consistent supervision for residents who were assessed and identified as smokers, b) residents who required close monitoring when smoking, did not keep their own lighting materials and then used it to light other residents' cigarettes (Resident #30 and #72), c) residents who required close monitoring and supervision while smoking, were assisted and supervised to prevent embers from the cigarettes from causing burn holes and ensuring the lit cigarette was not rested on the smoking apron causing cinder type marks (Resident #29), and d.) extinguishing cigarettes into appropriate receptacles [...]

Inspectors wroteBased on interviews, review of medical records (MRs), other facility documentation, and review of facility policy, it was determined that the facility failed to a.) protect residents from physical and sexual abuse as well as b.) ensure adequate supervision for a severely cognitively impaired resident (Resident #84) with a history of wandering, from wandering into other resident rooms, leading to physical altercations and sexual abuse involving other residents. Due to the vulnerable nature of the nursing home population, there is a potential for serious injury or serious physical or psychosocial impairment from being physically shoved by Resident #152 and Resident #94 as well as Resident #84 sexually abusing residents. This required immediate action to prevent further events of physical and sexual abuse by or to Resident #84 or other residents. [...]

Inspectors wroteComplaint #s NJ 163250, NJ 170219 Based on observation, interview, record review and review of other pertinent documents, it was determined that the facility failed to ensure a thorough and complete investigation was completed to determine the causal factor of injuries of unknown origin to ensure that resident abuse or neglect had not occurred for: [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure dependent residents were provided with routine and appropriate incontinence care and nail care in a timely manner. This deficient practice was identified for 8 of 8 residents reviewed for Activities of Daily Living Care (Residents #27, #30, #37, #41, #82, #94,# 95, and #155) and was evidenced by the following: 1) On 6/27/24 at 10:48 AM, surveyor #1 entered Resident #94's room and noted a strong odor of feces in the room. Resident #94 informed the surveyor that staff refused to assist with incontinence care. Upon request, Resident #94's roommate activated the call bell. The Licensed Practical Nurse/ Unit Manager (LPN/UM) reported to the room immediately, and confirmed that Resident #94 needed to be changed. [...]

Inspectors wroteComplaint #167264 Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure sufficient and competent staff were available to a) provide timely and appropriate incontinence care for residents who were dependent on staff for Activities of Daily Living (ADL's) care (Residents #94, #30, #37, #41, #95, and #27), b) provide nail care for a resident who was dependent of staff for ADL's (Resident #82) and c) ensure staff were competent to accurately document an allegation of sexual abuse and alert the supervisor. The deficient practice had the potential to affect all residents and was evidenced by the following: Refer to 600 K and 677F a) On 6/27/24 at 10:48 AM, surveyor #1 was doing the initial tour of the facility and was informed by Resident #94 that staff refused to change them. [...]

Inspectors wroteBased on observation, interview and document review it was determined that the administrator failed to ensure the facility operated in a manner to ensure residents were consistently provided with care to maintain their highest practicable physical, mental, and psychosocial well-being by failing to ensure: a) a process was in place to ensure a resident (Resident #84) with known wandering behaviors was effectively supervised to prevent the resident from sustaining an injury and preventing the resident from sexually abusing another resident (Resident # 94, b) adverse and significant events were thoroughly investigated (Resident #81 and #150, Resident #94), c) wound care was consistently documented to ensure that staff were able to identify and report any change in a wound condition to the physician. [...]

Inspectors wroteBased on interview and document review it was determined that the facility failed to have an effective systems and procedures for feedback in place to self identify areas for Quality Assurance and Perforamance Improvement (QAPI) for: [...]

Inspectors wroteBased on observation, interview, record review and review of other facility provided documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure, a.) prescription medications were labeled and accounted for, b.) expired supplies were identified and removed from active inventory, c.) supplies that required dating were dated and d.) to consistently maintain accurate administration, reconciliation, and accountability of dispensed controlled dangerous substance (narcotic medication) stored within the electronic back-up machine (EBM). This deficient practice was identified for one (1) of two (2) medication rooms, two (2) of eight (8) medication carts and one (1) of one (1) EBM inspected for the medication storage and labeling. The evidence was as follows: Reference: [...]

Inspectors wroteBased on interview and document review, it was determined that the facility failed to ensure they reported to the Department of Health (DOH) as required, a resident who was confused, wandered, identified as being exit seeking, and who broke a latch on a window and exited to the outside. This deficient practice occurred for 1 of 9 residents reviewed for accidents (Resident #87) and was evidenced by the following: On 07/02/24 at 12:00 PM, the surveyor reviewed the electronic medical record for a resident identified as a smoker, Resident #87. A Nurses Progress Note, created by a Liscensed Practical Nurse (LPN) on 05/12/2024 at 21:48 [8:21 PM] revealed Informed by an aide that the resident had jumped out of window and primary nurse and aide was with the resident. The nurse remained with the resident while staff brought the wheelchair out and brought the resident back in. [...]

Inspectors wroteBased on interview, and record review, it was determined that the facility failed to complete a Significant Change in Status Assessment using the Resident Assessment Instrument (RAI) process on a resident who elected hospice benefits. This deficient practice was identified for 1 of 2 residents reviewed for hospice (Resident #44). This deficient practice was evidenced by: According to the Center for Medicare/Medicaid Services (CMS) - Resident Assessment Instrument (RAI) 3.0 Manual, A significant change in status assessment (SCSA) is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow a physician's order for the application of resting hand splint to the right hand for one resident. The deficient practice was identified for 1 of 1 resident (Resident #71) reviewed for positioning and mobility, and was evidenced by the following: On 6/27/24 at 10:30 AM, the surveyor toured the unit. During the tour of the facility, Resident #71 reported some concerns with lack of physical therapy and assistance with Range of Motion (ROM) to prevent further contractures to the right hand. The resident used the left hand to pick up the right hand under the cover and show the contracted hand to the surveyor. The right hand was contracted, the fingers were curled into the palm of the right hand. [...]

Inspectors wroteBased on interview, record review and review of pertinent documents it was determined that the facility failed to ensure the facility followed-up regarding resident goals and preferences regarding nutrition, and to ensure a comprehensive nutritional assessment accurately reflected resident goals. The deficient practice was evidenced for 1 of 1 resident reviewed for receiving nutrition via a tube (Resident #75) and was evidenced by the following: Reference It is the position of the Academy of Nutrition and Dietetics that all Americans aged 60 years and older receive appropriate nutrition care; have access to coordinated, comprehensive food and nutrition services; and receive the benefits of ongoing research to identify the most effective food and nutrition programs, interventions, and therapies. [...]

Inspectors wroteBased on observation, interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to ensure adequate indication, and a gradual dose reduction (tapering towards an optimal dose) of an antipsychotic medication was attempted annually to establish an optimal dose, for a hemipelagic resident with congestive heart failure (Resident #62). This deficient practice was identified for one (1) of five (5) residents reviewed for unnecessary medications and was evidenced as follows. Reference: A review of the manufacturer's specifications for Seroquel (quetiapine) under the black box warning reflected Warning: Increased Mortality In Elderly Patient with dementia related psychosis and suicidal thoughts and behaviors. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to minimize the potential spread of infection to residents during medication administration for 1 of 2 nurses observed during the medication pass on 1 of 2 units (North Wing). This deficient practice was observed and evidenced by the following: On 6/28/24 at 7:00 AM, the surveyor observed signage posted at the entrance door which read: Enhanced Barriers Precautions Stop. Everyone must clean their hands before entering and exiting the room. Providers and suppliers must also wear gloves and gown during high contact Resident Cares activities, or devices care. On 06/28/22 at 7:15 AM, the surveyor observed the Licensed Practical Nurse (LPN) prepare medications for Resident #71. [...]

Inspectors wroteBased on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to: a.) implement interventions to prevent the development of a stage IV facility acquired pressure injury, b.) ensure individualized comprehensive care plan interventions were implemented to prevent facility acquired pressure injury wound from worsening, and c.) ensure daily observation during wound care was documented according to professional standards of Nursing practice to follow continuity of care, and d) alert physician of any change in the wound condition. This deficient practice occurred for 1 of 2 closed records reviewed for wounds (Resident #150). [...]

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to: 1. monitor the level of sanitizer in the three-compartment sink; and 2. perform hand washing and change gloves in between tasks during the initial tour of the kitchen. These failures had the potential to increase the risk of food-borne illness for the 100 residents receiving food from the kitchen out of the 103 residents residing in the facility.

Inspectors wroteBased on interviews, observations, record review, and policy review, the facility failed to honor a resident's request to attend activities during the administration of a tube feeding (liquid nutrition via a tube inserted through the abdomen into the stomach) for one of six residents (Resident (R) 88) reviewed for choices out of a total sample of 39 residents.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure resident care plan meetings were conducted routinely for three Residents (R) R19, R35, and R77 of 39 sampled residents.

Inspectors wroteBased on record review, observations, interview, and review of facility policy, the facility failed to ensure appropriate care of a gastrostomy (g)-tube during medication administration for one resident (R) R 88 of one resident who were reviewed during medication administration with a tube feeding. The facility further failed to label the resident's tube feeding with the name of the formula, the date and time the formula was started, and/or the rate of infusion.