Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Winder Center For Nursing And Healing during CMS and state inspections, most recent first.
Failure to Provide Transfer and Bed-Hold Notices After Hospital Transfers: The facility did not provide required written transfer/discharge notices or bed-hold notices to residents or their RRs after emergent hospital transfers. Records for four residents showed repeated ER/hospital send-outs and returns, with diagnoses including paraplegia, metabolic encephalopathy, post-stroke hemiplegia/hemiparesis, and spastic hemiplegia with dysphagia. The BOM confirmed the notices were not given when residents were transferred out to the hospital.
Improper Cleaning and Air-Drying of Food Service Equipment: Kitchen staff failed to fully clean and air-dry multiple pans and food service equipment before stacking them for use. The DM confirmed several pans were still wet and some had food residue remaining, and the can opener blade also had food residue.
Open Trash Dumpsters: Two dumpsters used for facility trash were observed with their top lids open in the enclosed parking lot area behind the building. The DM stated the dumpsters are supposed to be closed and noted that other staff use them as well, while being unsure why this responsibility fell on the kitchen.
The facility failed to ensure antibiotics were used only when a diagnosed infection was present and failed to maintain required antibiotic stewardship monitoring. Monthly infection line listings for multiple months lacked culture/x-ray results, supporting documentation for McGeer criteria determinations, infection type, resolution status, and antimicrobial stewardship form completion. For later months, the facility used an order listing report instead of the monthly line listing, and some antibiotics continued without rationale. There was also no documentation that the IP provided staff education or shared antibiotic usage reports with the Medical Director, providers, or nursing staff.
Failure to complete a Level II PASARR after a resident received a post-admission mental illness diagnosis. The resident’s PASRR Level I showed no mental illness diagnosis, but a psychiatric eval later documented PTSD, and no additional PASARR was completed afterward. The SSD confirmed no further PASARR had been done and that a Level II should have been completed; the Administrator stated the expectation was that a Level II PASARR would be completed when an existing resident received a mental illness diagnosis.
Food was not served at a palatable temperature for four sampled residents. One resident said meals tasted cold, another said food was overseasoned and vegetables were overcooked, and two others said trays were delivered cold. Observations showed food on the steam table was hot, but a later test tray delivered to the unit cooled to 115 degrees F, 99 degrees F, and 101 degrees F before the last resident was served. The DM stated the food was cool and would taste better warmer.
Hand hygiene was not performed after a CMA administered inhaled Advair to a resident with COPD and a current order for Advair 250/50 diskus BID. The CMA handled the diskus with an ungloved hand, returned it to the med cart, and touched the cart computer, drawers, and multiple medication containers before sanitizing her hands. The facility policy required hand hygiene before and after direct resident contact, and leadership acknowledged the infection control lapse.
Pneumococcal Vaccine Assessment and Consent Documentation Missing: The facility failed to follow its pneumococcal vaccine policy for two residents. One resident had documentation of PPSV23 but no record that PCV15 or PCV20 was offered or given later, and a prior PCV13 refusal was not supported by a signed consent. Another resident had no documented pneumococcal immunization history, no evidence of vaccine education, and no signed refusal form, which the IP confirmed during interview.
A resident reviewed for COVID-19 immunization was documented as refusing the vaccine, but the EMR contained no record that the resident received education on the risks, benefits, or potential side effects before declining. The IP confirmed there was also no declination/consent form in the record, despite the facility policy requiring education, offering the vaccine, and documenting the resident’s vaccination status.
A resident with multiple diagnoses and severe cognitive impairment was at risk for pressure ulcers, but the facility failed to follow the care plan for skin assessments. Despite a physician's order for weekly assessments, documentation ceased after a CNA reported an open area on the sacrum. The lack of follow-up led to an unstageable wound, highlighting a significant deviation from the facility's care plan policy.
A resident at risk for pressure ulcers developed a sacral wound that was not properly assessed or treated, leading to a severe deterioration in their condition. Despite facility policies requiring weekly skin assessments, these were not consistently completed, and the recommended treatment for the wound was not implemented. Communication and documentation failures among staff contributed to the resident's condition worsening to septic shock, resulting in hospitalization.
A facility failed to accurately document a resident's advanced directive in the EMR. The resident, with multiple diagnoses and a BIMS score indicating cognitive intactness, had a POLST form signed for DNR status. However, the care plan inaccurately listed the code status as FULL CODE. This error was confirmed by the DON and the resident.
The facility failed to provide the required NOMNC and SNF ABN to two residents discharged from Medicare Part A coverage. One resident remained in the facility, while the other returned home. The Business Office Manager indicated that new Social Services and Therapy employees did not provide these documents upon discharge.
A facility failed to monitor blood glucose levels for a diabetic resident receiving insulin, as there were no specific orders for glucose monitoring upon admission. Despite daily insulin administration, no glucose monitoring was documented until the resident was transferred to the hospital with an altered mental status. Interviews revealed a lack of communication and oversight in ensuring blood glucose monitoring was conducted, as per professional standards.
A facility failed to obtain a physician order for colostomy care for a resident with a history of ulcerative colitis and intestinal obstruction. Despite the facility's policy requiring a licensed nurse to determine the type of ostomy and collaborate with the attending physician, the resident's EMR and MAR lacked orders for colostomy care. Interviews with the DON and an LPN confirmed the absence of these orders, leading to inadequate care management for the resident, who was at risk for skin breakdown.
Failure to Provide Transfer and Bed-Hold Notices After Hospital Transfers
Penalty
Summary
The facility failed to provide residents and their Resident Representatives with the required written transfer/discharge notices and bed-hold notices after emergent hospital transfers for four sampled residents. The facility policy titled Transfer and Discharge [including Against Medical Advice (AMA)] stated that transfer/discharge notices would include the reason for transfer or discharge, the effective date, the destination, appeal rights, appeal hearing information, assistance with appeal requests, and Ombudsman contact information. The Bed Hold Prior to Transfer policy stated that written bed-hold information would be provided at the time of transfer for hospitalization, or within 24 hours for an emergency transfer, and that a signed and dated copy would be kept in the resident's record. R93 had an admission date of 9/9/2025 and a readmission date of 1/16/2026, with diagnoses of paraplegia and an unstageable pressure ulcer. His quarterly MDS with an ARD of 12/16/2025 showed a BIMS score of 15 out of 15, indicating intact cognition. Progress notes documented a change of condition on 1/2/2026 with a send-out to the ER, a readmission from the hospital on 1/4/2026, another send-out to the ER for antibiotic therapy on 1/9/2026, and arrival from the hospital on 1/16/2026. R10 had an admission date of 9/4/2025 and a diagnosis of metabolic encephalopathy, with a quarterly MDS ARD of 1/14/2026 showing a BIMS score of 14 out of 15. Progress notes showed multiple hospital transfers and returns, including an unresponsive, seizure-like episode with 911 called on 10/5/2025, return from the hospital on 10/8/2025, abnormal labs with transport to the hospital on 11/14/2025 and return on 11/18/2025, and another ER transfer on 12/19/2025 with arrival back on 12/24/2025. R155 had an admission date of 12/15/2025 with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the left side. His admission MDS with an ARD of 12/21/2025 showed a BIMS score of 11 out of 15, indicating moderate impairment. Progress notes documented that on 12/28/2025 the NP was notified of ongoing respiratory distress and increased oxygen requirement and ordered transfer to the ER for further evaluation. R34 had an original admission date of 2/6/2019 with diagnoses of spastic hemiplegia affecting the left nondominant side, dysphagia, and pressure ulcer, and progress notes showed hospital transfers for seizure on 8/24/2025 and for elevated heart rate and temperature on 10/25/2025. Review of the records for all four residents showed no documentation that transfer notices or bed-hold notices were provided to the residents or their resident representatives, and the BOM confirmed in interview that the facility did not provide these notices when residents were transferred to the hospital.
Improper Cleaning and Air-Drying of Food Service Equipment
Penalty
Summary
The facility failed to ensure kitchen staff thoroughly cleaned and air-dried pots, pans, and food service equipment before storage, as required by the facility’s Sanitation policy. During observation and interview, the Dietary Manager confirmed that six pans measuring 6 inches by 12 inches by 4 inches, three pans measuring 10 inches by 12 inches by 4 inches, three pans measuring 6 inches by 10 inches by 4 inches, and one pan measuring 18 inches by 24 inches by 1 inch were cleaned and stacked for use while still wet, with some pans still showing food residue. The pans had been stacked before adequate air-drying, and the can opener blade was also observed to have food residue.
Open Trash Dumpsters
Penalty
Summary
Improper disposal and containment of garbage and refuse was identified in two of the two dumpsters used by the facility. The facility’s policy titled Food-Related Garbage & Rubbish Removal, dated April 2024, states that food-related garbage and rubbish must be disposed of in accordance with local and state laws, kept in containers, stored in a manner inaccessible to vermin, and that outside dumpsters must be kept closed, have a drain plug in place, and be free of surrounding litter. During an observation and interview on 1/19/2026 at 10:00 am with the Dietary Manager in the enclosed parking lot area behind the building where the dumpsters were located, the top lids of both dumpsters used for the facility’s trash were observed to be open. The Dietary Manager stated that the dumpsters are supposed to be closed and added that other staff use them also, and was unsure why this fell on the kitchen.
Antibiotic Stewardship Monitoring and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure antibiotics were prescribed only when a diagnosed infection was present for eight of 12 months of antibiotic stewardship reviewed. The facility’s Antibiotic Stewardship Program policy stated that antibiotic use protocols and a system to monitor antibiotic use were to be in place, that McGeer’s Criteria were to be used to determine whether to treat an infection with antibiotics, and that at least one outcome measure associated with antibiotic use would be tracked monthly. The policy also required annual written feedback on antibiotic use data to administration, medical and nursing staff, the QAA Committee, the Medical Director, and education for staff, prescribing practitioners, residents, and families. A review of the January through June 2025 Monthly Infection Line Listings showed repeated gaps in documentation for residents receiving antibiotics. In January, 16 of 39 residents had no culture/x-ray result documented, and there was no documentation supporting how McGeer criteria were determined as yes, no, or n/a; the document also lacked information on whether infections were HAI or community-acquired, whether they resolved, and whether the antimicrobial stewardship form was completed. Similar missing documentation was found in February, March, April, May, and June, including multiple residents with no culture/x-ray results, some hospice-related notations, and no supporting documentation for McGeer determinations. The line listings also frequently lacked documentation on infection type, resolution, and completion of antimicrobial stewardship forms. For July and August 2025, the Monthly Infection Line Listing was not used and was replaced by an Order listing report that only identified residents’ names, antibiotics ordered, order dates, and whether the antibiotic was discontinued or completed. For some residents, antibiotics continued without any rationale. The January through August 2025 documentation showed that infection types were identified each month, but there was no documentation that the IP provided in-service education to nursing staff, discussed the types and number of infections, or gave the Medical Director or providers a report of antibiotic usage. During interviews, the DON and IP were informed of the missing documentation and the absence of annual reports, and the DON later confirmed there was no additional information and no evidence that annual reports or provider feedback had been shared.
Failure to Complete Level II PASARR After New PTSD Diagnosis
Penalty
Summary
The facility failed to complete a Level II PASARR evaluation after a resident received a post-admission mental illness diagnosis. A review of the facility policy titled Resident Assessment- Coordination with PASRR Program stated that residents with a newly evident or possible serious mental disorder, intellectual disability, or related condition are to be referred promptly for a Level II resident review. In this case, the resident had an original admission date of 8/13/2014 with diagnoses including hypertensive heart disease and chronic kidney disease with heart failure, hypertension, and alcoholic cirrhosis of the liver without ascites. Record review showed the resident’s PASRR Level I assessment had no mental illness diagnosis and no Level II PASARR was completed. The resident’s psychiatric diagnostic evaluation dated 6/19/2018 documented a diagnosis of PTSD, but further review of the EMR and facility documents found no additional PASARR completed after that diagnosis. During interviews, the Social Service Director stated there had not been any additional PASARRs completed after the 2018 diagnosis and confirmed that a Level II should have been completed, and the Administrator stated the expectation was that a Level II PASARR would be completed when an existing resident received a diagnosis of mental illness.
Food Served at Improper Temperature
Penalty
Summary
Food was not served at a palatable temperature for four sampled residents, including three residents who were cognitively intact and one resident with moderately impaired cognition. R131 stated that meals tasted cold. R93 stated that the food was overseasoned and the vegetables were overcooked. R160 stated that meal delivery caused the food on his tray to taste cold because carts were not served by nursing staff until much later after arriving on the unit. R48 also stated that the food served on her meal tray was cold when delivered to her room. During observations, lunch items on the steam table were measured at hot temperatures, including lasagna and peas at 186 to 198 degrees F for regular texture and 162 to 190 degrees F for puree texture. However, during a later observation, a test tray delivered to the 600 hallway was found to have cooled significantly by the time the last resident was served, with lasagna at 115 degrees F for regular texture, lasagna at 99 degrees F for puree texture, and peas at 101 degrees F for puree texture. The Dietary Manager stated that the taste and texture were okay, but the temperature was cool and would probably taste better if it were warmer. The Administrator stated that food served to residents was expected to be at the appropriate temperature for the specific item.
Hand Hygiene Not Performed After Inhaled Medication Administration
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when hand hygiene was not performed after the administration of inhaled medication for one resident. During medication administration, a Certified Medication Assistant sanitized her hands, set up medications, and prepared Advair Diskus for a resident with COPD and a current order for Advair 250/50 diskus twice daily. The CMA removed the diskus from its box, manually slid open the cover over the mouthpiece with an ungloved hand, loaded a dose, and handed the device to the resident, who inhaled the medication and returned the diskus to the CMA. After receiving the diskus back, the CMA closed the opening with her ungloved hand, placed the medication back in its box, returned it to the medication cart, and then used the cart computer, opened drawers, and touched multiple medication bottles and boxes before sanitizing her hands. The facility policy stated hand hygiene is the primary means to prevent the spread of infections and requires hand hygiene before and after direct contact with residents. During interview, the CMA stated she usually uses gloves to give Advair and that she washes her hands after medications. The Administrator acknowledged infection control risk associated with lapses in handwashing, and the Director of Operations stated handwashing should be standard practice.
Pneumococcal Vaccine Assessment and Consent Documentation Missing
Penalty
Summary
The facility failed to ensure that pneumococcal vaccinations were offered and documented in accordance with its policy and current CDC guidance. A review of the policy titled "Pneumococcal Vaccine (Series)" showed that residents are to be assessed for pneumococcal immunization on admission, educated about the benefits and side effects before the vaccine is offered, and asked to sign a consent form if they refuse. The policy also stated that adults 65 years or older who had only received PPSV23 should receive one dose of PCV15 or PCV20 at least one year after the most recent PPSV23 vaccination. For one resident, the EMR showed PPSV23 had been given, but there was no documentation that PCV15 or PCV20 was offered or administered one year later; the EMR also indicated PCV13 was refused, but there was no signed refusal form. For another resident, the EMR contained no documentation that any pneumococcal vaccine had been administered or refused, and the IP confirmed there was no evidence the facility obtained the resident's pneumococcal immunization history on admission, provided education about the vaccine, or secured a signed consent documenting refusal. The IP confirmed these documentation gaps during interview.
Failure to Document COVID-19 Vaccine Education and Refusal
Penalty
Summary
The facility failed to ensure that one of five residents reviewed for COVID-19 immunization, R58, received education regarding the risks and benefits of the COVID-19 vaccine and booster before declining vaccination. The facility policy titled COVID-19 Vaccination stated that residents would be educated and offered the COVID-19 vaccine and that the medical record would include documentation of education regarding the risks, benefits, and potential side effects of the vaccine, as well as documentation if the resident refused vaccination. R58 was admitted to the facility on 3/23/2023. Review of the EMR immunization record showed no documentation indicating whether any COVID-19 vaccines or boosters were administered or refused. The Infection Preventionist provided the admission contract, which indicated that R58 refused the COVID-19 vaccine, but there was no documentation that the resident had been educated about the benefits and potential side effects of the immunization or that a declination/consent form was signed. During interview, the Infection Preventionist confirmed that the facility had no documentation showing that the policy was followed for R58.
Failure to Follow Care Plan for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to adhere to the care plan for a resident, identified as R145, who was at risk for pressure ulcers. R145 was admitted with multiple diagnoses, including encephalopathy due to subdural hematoma, chronic kidney disease, and cerebrovascular accident with hemiplegia. The resident was cognitively impaired and dependent on staff for all activities of daily living. The care plan for R145, dated 11/29/2023, included interventions for daily skin assessments, keeping the skin dry, and monitoring nutrition. However, the facility did not follow through with these interventions, as evidenced by the lack of documented skin assessments after 2/16/2024, despite a physician's order for weekly skin assessments. On 2/16/2024, a CNA reported an open area on R145's sacrum to an LPN, but there was no documented follow-up or additional skin assessments recorded in the medical record. The facility's failure to document and address the skin condition led to the development of an unstageable wound on the sacrum, which was identified by a Wound Nurse Practitioner on 3/27/2024. This oversight in care and documentation was a significant deviation from the facility's policy on comprehensive, person-centered care plans, which should include measurable objectives and timetables to meet the resident's needs. Interviews with facility staff revealed a lack of adherence to the care plan and communication breakdowns. The Corporate Wound Nurse indicated that CNAs are responsible for examining the skin during bathing and reporting changes to the unit nurse, while the MDS Coordinator emphasized the importance of following care plan interventions. Despite these protocols, the facility's staff did not consistently perform or document the required skin assessments, contributing to the resident's deteriorating condition.
Removal Plan
- R145 was discharged from the facility to the hospital for a septic wound and did not return to the facility.
- An AD-HOC meeting was held with the Administrator, Director of Nursing, Regional Director of Operations, Regional Director of Clinical Operations, and Chief Medical Officer to address the concerns identified related to the Immediate Jeopardy Citations.
- The RDO, RDCO, and CMO reviewed the center policy on Developing a Comprehensive Care Plan. No policy changes or recommendations were made because of this review.
- A Root Cause Analysis of the wound management system breakdown was completed by RDO, RDCO, CMO, Administrator and DON. Documentation of analysis was put on the RCA Tool and was included in the Ad Hoc Quality Assurance Performance Improvement QAPI meeting. The Root Cause for the immediate jeopardy was identified as staff not following the center's policy for Pressure Ulcer Prevention and Management secondary to education deficit.
- All residents had a pressure ulcer risk assessment performed. Care plans were reviewed and updated by the MDS Coordinators for 139 of 140 residents to ensure that the weekly skin check was listed as an intervention under the at-risk skin care plan.
- The center MDS Coordinator, Wound Care Nurse, and Regional Wound Care Specialist conducted an audit for 5 of 5 residents with pressure ulcers/injuries to ensure that all residents have a comprehensive wound care plan that is being implemented.
- Nursing employees, 6 of 7 RN's, 27 of 29 LPN's and 43 of 46 CNA's were educated by the RWCS, Staff Development Coordinator, and DON on implementation of the care plan for pressure ulcer prevention and management including location of the care plan in the electronic health record and viewing the care plan prior to the start of the shift. LPNs were educated regarding following physicians orders and the person-centered care plan. Any staff not educated during the initial education will have the education prior to the start of their shift or during the orientation period.
- Review of the root cause analysis showed LPNs and CNAs were educated to ensure weekly skin assessments will be completed on a weekly basis and documented. DON will ensure the completion of assessments in a timely manner. The DON verified the DON in-serviced staff along with RN PP. The DON stated CNAs were re-educated on how to fill out shower sheets (and give a copy to the charge nurse and DON), as soon as a skin condition was identified and to notify the nurse immediately.
- Review of a Daily Census revealed 139 of 140 residents were reassessed for risk for pressure ulcers and that residents had a care plan to include weekly skin assessments. This was verified by review of the pressure ulcer risk assessments and care plans for R12, R395, R400, R402 and R403.
- Review of the pressure Ulcer/Injury Care Plan Update Tool revealed 5 of 5 residents care plans were reviewed for accuracy of wound location and care plan reflective of care provided. Review of five residents, R12, R395, R400, R402 and R403, showed the residents had comprehensive care plans for pressure ulcers.
- Review of in-service sign in sheets revealed 27 of 29 LPNs, 43 of 46 CNA's and 6 of 7 RN's were in-serviced by the RWCS on care plans for pressure ulcer prevention and management.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development and worsening of pressure ulcers for a resident, identified as R145. The resident was admitted with diagnoses including encephalopathy due to subdural hematoma, chronic kidney disease, and cerebrovascular accident with hemiplegia. The resident was at risk for pressure ulcers but had none at the time of the initial assessment. However, an open area on the sacrum was reported by a CNA on 2/16/2024, but there was no documented follow-up or treatment for this wound. The facility's policy required weekly skin assessments and documentation of any pressure injuries, but these were not consistently completed for R145. The last documented skin assessment was on 3/1/2024, and there was no mention of a sacral wound. Despite a CNA reporting the sacral wound, it was not documented or treated until it was identified as an unstageable wound by a Wound NP on 3/27/2024. The recommended treatment by the NP was not implemented, and the wound worsened significantly, leading to the resident's hospitalization. Interviews with staff revealed a breakdown in communication and documentation processes. The LPN on duty did not recall being informed about the sacral wound, and the wound nurse was not notified in a timely manner. The facility's system for reporting and documenting skin issues was not followed, contributing to the resident's condition deteriorating to septic shock and necessitating hospitalization.
Removal Plan
- An Ad-Hoc meeting was held with the Administrator, Director of Nursing, Regional Director of Operations, Regional Director of Clinical Operations, and Chief Medical Officer to address the concerns identified related to the Immediate Jeopardy Citations.
- The RDO, RDCO, and CMO reviewed the facility policy regarding Pressure Ulcer Prevention and Management. Facility did not make any policy changes or recommendations on this review.
- A Root Cause Analysis regarding the pressure ulcer prevention and skin management system was completed by RDO, RDCO, CMO, Administrator and DON. Documentation of the RCA was put on the RCA Tool and was included in the Ad-Hoc Quality Assurance Performance Improvement meeting. The Root Cause for the immediate jeopardy was identified as staff not following the center's policy for Pressure Ulcer Prevention and Management secondary to education deficit.
- The facility Unit Managers and Wound Care Nurse conducted skin assessments on 131 of 140 residents residing in the center. Audit revealed no new in-house acquired pressure ulcers/injuries.
- Five of five residents residing in the center identified with pressure ulcers/injuries were reassessed including measurements and documented on by the wound care nurse practitioner.
- Orders were verified for five of five Residents with pressure injuries by the Regional Skin Management Specialist to ensure orders in the electronic medical administration record matched the recommendations of the wound care nurse practitioner. The facility implemented an audit conducted by the DON after each wound care nurse practitioner visit to ensure the orders match the recommendations of the wound care nurse practitioner. This audit will be conducted once a week.
- Nursing employees 6 out of 7 registered nurses, 27 out of 29, licensed practical nurses and 43 out of 46 certified nursing assistants were educated by the Regional Wound Care Specialist Staff Development Coordinator, and DON on the pressure ulcer prevention and treatment. Specifically, CNAs received education to notify the licensed nurse anytime a new skin area was identified and to document the findings on the body sheet. The LPNs/RNs received education on conducting weekly skin assessments and notifying the Medical Provider or Wound Care Nurse Practitioner anytime a new skin area is identified as well as following physician orders and plan of care for wound care treatments. Anyone that was not educated during the Initial education sessions will be educated prior to start of their shift or during the orientation process.
- The Regional Skin Management Specialist educated three of three wound care nurses on ensuring pressure wounds are measured weekly and are assessed on the Weekly Wound Assessment Tool.
- 139 of 140 residents' charts were audited the DON will ensure staff have an order to perform a weekly skin check.
- The facility implemented a process to ensure that skin checks are monitored daily to ensure completion. The DON will conduct daily audits to ensure skin checks are completed daily and to ensure any newly identified pressure ulcer was reported to the MD or Wound Care Provider and an appropriate treatment ordered.
Inaccurate Documentation of Advanced Directive in EMR
Penalty
Summary
The facility failed to ensure the accurate documentation of an advanced directive in the Electronic Medical Record (EMR) for a resident, identified as R397. R397 was admitted with multiple diagnoses, including Sepsis, Chronic Diastolic Heart Failure, Acute Kidney Failure, Respiratory Failure with Hypoxia, Psoriatic Arthritis, and Hyperlipidemia. The resident was cognitively intact, as indicated by a BIMS score of 13. A POLST form dated 7/24/2024, signed by R397 and medical personnel, indicated a code status of Allow Natural Death - Do Not Attempt Resuscitation (DNR). However, the care plan dated 9/24/2024 inaccurately documented the resident's code status as FULL CODE. This discrepancy was confirmed by the Director of Nursing during an interview, and the resident also confirmed the correct DNR status during a separate interview.
Failure to Provide Required Medicare Notices
Penalty
Summary
The facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to two residents who were discharged from Medicare Part A coverage. Resident 94 was discharged from Medicare Part A skilled services and remained in the facility, while Resident 397 was discharged and returned home. There was no documented evidence that these notices were provided to either resident or their responsible parties. During an interview, the Business Office Manager revealed that the facility did not provide the necessary documents to the residents. The manager attributed this failure to the fact that the Social Services and Therapy employees were new to the facility and did not provide the documents upon discharge from Medicare Part A skilled services.
Failure to Monitor Blood Glucose in Diabetic Resident Receiving Insulin
Penalty
Summary
The facility failed to ensure professional standards were followed for blood glucose monitoring of a resident receiving insulin. The facility's policy on Blood Glucose Monitoring did not include a protocol for residents receiving insulin, and there was no documentation of blood glucose monitoring for the resident in question. The resident, who had a diagnosis of diabetes mellitus, was admitted with orders for insulin Glargine but without specific orders for blood glucose monitoring. Despite receiving insulin daily, there was no evidence of glucose monitoring from the time of admission until the resident was transferred to the hospital. The resident was transferred to the hospital due to an altered mental status, where they were diagnosed with a complicated urinary tract infection. Interviews with facility staff revealed a lack of clarity and communication regarding the need for blood glucose monitoring. The Chief Medical Officer stated that blood sugars should be monitored daily for residents on long-acting insulin, even if not specified in hospital discharge orders. However, the Licensed Practical Nurse and the Director of Nursing indicated that the omission of fingerstick orders was an oversight, and the admission nurse failed to clarify the need for such orders with the Nurse Practitioner.
Failure to Obtain Physician Order for Colostomy Care
Penalty
Summary
The facility failed to obtain a physician order for colostomy care for a resident who required such services. The facility's policy on ostomy care mandates that a licensed nurse should determine the type of ostomy through physical assessment and collaboration with the attending physician as part of the comprehensive assessment and care planning process. However, the resident's Electronic Medical Record (EMR) and Medication Administration Record (MAR) lacked any physician orders for colostomy care, including the necessary supplies and frequency for changing the colostomy drainage bag. This oversight was confirmed during interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN), who acknowledged the absence of the required orders on the MAR. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14, had a history of ulcerative colitis and intestinal obstruction, and was at risk for skin breakdown due to the colostomy. The resident reported having to clean the stoma multiple times, indicating a lack of proper care management. The care plan initiated for the resident included colostomy care every shift and as needed, but without the necessary physician orders, the care was not documented or administered as required. This deficiency highlights a gap in the facility's adherence to its own policies and procedures for ostomy care management.
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Illustrative
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Winder
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park Place Nursing Facility | 12.5 mi | ★★★★★ | 0 | 0 |
| Mesun Health And Rehabilitation Center | 14.6 mi | ★★★★★ | 9 | 0 |
| University Nursing & Rehab Ctr | 16.3 mi | ★★★★★ | 0 | 0 |
| Presbyterian Village - Athens | 16.6 mi | ★★★★★ | 1 | 0 |
| High Shoals Health And Rehabilitation | 16.8 mi | ★★★★★ | 0 | 0 |
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