Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Wynfield Park Health And Rehabilitation during CMS and state inspections, most recent first.
A registered nurse assisted a resident with their meal while standing and not interacting, contrary to facility policy requiring staff to sit at eye level and engage with residents during meals. Interviews confirmed that staff are expected to provide dignified and respectful meal assistance by sitting and interacting with residents.
A resident with severe cognitive impairment and mobility limitations was found physically restrained in bed by a Geri-chair and regular chair placed against the bed, blocking her ability to exit. Staff interviews confirmed the chairs were used to prevent the resident from climbing out, but this was not documented as a restraint, and the care plan did not indicate restraint use.
A resident with quadriplegia, aphasia, and a neck contracture did not have the use of a neck pillow/support included in their care plan, despite an order for its use. The care plan only addressed general assistance with ADLs and safety, omitting this specific intervention. The DON confirmed the omission, and staff were expected to follow care plans and document refusals, but the neck pillow was not documented as an intervention.
A resident with quadriplegia and a neck contracture did not receive a physician-ordered neck pillow for head support, as observed during multiple checks. The care plan lacked documentation of this intervention, and staff confirmed the expectation to provide the device. The neck pillow was not present in the resident's room, indicating a failure to follow orders and care planning for range of motion support.
A kitchen aide was observed serving food without a required hair restraint, contrary to facility policy mandating hairnets or beard restraints in food service areas. The aide acknowledged forgetting to wear the hair net, and the Dietary Manager confirmed the expectation for staff to use hair restraints to prevent contamination. This failure had the potential to impact 54 residents receiving oral diets.
A resident with severe cognitive impairment, a stage 4 pressure ulcer, an indwelling urinary catheter, and a feeding tube did not receive proper infection control measures when a CNA failed to wear a gown during bathing and wound care, despite clear EBP signage and facility policy requiring gown and glove use for high-contact activities. The deficiency was observed during care, and the CNA acknowledged the lapse.
A resident with a documented history of hypersexual behavior was admitted without a care plan to address her risks, leading to multiple incidents of inappropriate sexual contact with four male residents who had cognitive impairments. Staff were not informed of her behaviors or provided with interventions, and some incidents were not reported or investigated, with leadership assuming consent without proper assessment.
The facility did not report allegations of sexual abuse involving two severely cognitively impaired male residents who were unable to consent, after a female resident with a history of sexually inappropriate behavior engaged in hypersexual actions. The Administrator did not recognize the incidents as abuse and relied on staff input to determine consent, despite the residents' cognitive status, resulting in a failure to follow required reporting procedures.
The facility did not investigate incidents where a resident with a history of sexually inappropriate behavior was observed sitting on the lap of one male resident and stroking the face of another, both of whom were severely cognitively impaired and unable to consent. Staff and administration failed to recognize or assess these incidents as potential abuse, contrary to facility policy.
A resident with Myasthenia gravis and a history of unsteady gait was placed in a Geri-chair without a documented therapy assessment or inclusion in the care plan as a fall prevention measure. Staff interviews confirmed the resident was frequently observed in the Geri-chair, and concerns were raised by the Director of Rehabilitation and RN supervisor about the potential accident hazard. The decision to use the Geri-chair was made by nursing staff for comfort, not through interdisciplinary assessment, resulting in a deficiency related to accident hazards and inadequate supervision.
A resident with dementia was not provided a timely urinalysis after a physician order was received, as the RN failed to enter the order promptly. The delay was confirmed through grievance review and interviews, with the administrator and NP both stating that staff are expected to enter and follow physician orders.
A facility failed to obtain laboratory tests as ordered by a physician for a resident with multiple diagnoses, including CKD and hypertension. Despite orders for a Vitamin D Panel, CBC, CMP, and Uric Acid level, there was no evidence that these tests were conducted. The Administrator confirmed that the laboratory service did not draw the samples, and the facility did not follow up to ensure completion.
The facility failed to routinely assess and document pressure ulcers for two residents. One resident had a blister on the heel that was not measured or staged, and no further assessments were conducted until it was identified as a DTI. Another resident had a stage 2 pressure ulcer on the ankle, but no further assessments were recorded after a certain date, despite ongoing treatment. Interviews revealed a lack of consistent wound assessment and documentation, contributing to the deficiency.
Failure to Provide Dignified Meal Assistance
Penalty
Summary
A deficiency was identified when a registered nurse (RN) assisted a resident with their meal while standing, rather than sitting at eye level as required by facility policy. During the meal observation, the RN was seen standing next to the resident, watching other activities in the dining room, and not interacting with the resident during the meal. The facility's policy on meal service specifies that associates should promote and maintain patients' dignity and respect during meal service. Interviews with the RN, Assistant Dietary Manager, and Dietary Manager confirmed that staff are expected to sit next to residents and interact with them while providing meal assistance. The RN admitted to not following this protocol, stating she had not received training in dining room protocol and preferred not to sit. Both the Assistant Dietary Manager and Dietary Manager agreed that standing while assisting a resident is not dignified and that staff should sit at eye level and engage with residents during meals.
Resident Restrained by Chair Placement Against Bed
Penalty
Summary
A deficiency was identified when a resident was found physically restrained in bed by the placement of a Geri-chair and a regular chair against her bed, blocking her ability to get out on one side. The facility's policy states that residents have the right to be free from physical restraints unless required for medical treatment, and that assessment and consent are required prior to restraint use. The resident in question was severely cognitively impaired, had an impairment in one lower extremity, required substantial to maximum assistance with activities of daily living, and had a history of falls. There was no documentation in the care plan indicating a need for restraint. Multiple staff interviews confirmed that the chairs were intentionally placed to prevent the resident from climbing out of bed, but this was not reported or documented as a restraint. Observations on several occasions showed the chairs blocking the resident's exit from bed. Some staff recognized this as a potential restraint, while others did not report it. The Health Information Manager and other staff had previously noticed and moved the chairs, but the practice continued. The DON stated she had not observed this before and expected staff to report such situations.
Failure to Include Neck Pillow Intervention in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan with measurable goals and interventions for one resident, as required by their own policy and federal regulations. Specifically, the care plan for a resident with quadriplegia, aphasia, and dysphagia did not include documentation or interventions related to the use of a neck pillow/support, despite the resident having a neck flexion contracture and an order for the neck pillow. The care plan only addressed assistance with activities of daily living and promoting safety, omitting the specific intervention of the neck pillow. Staff interviews and record reviews confirmed that the resident's care plan did not reflect all necessary interventions for the contracted neck, as the use of the neck pillow was not included. The DON acknowledged that staff were expected to follow orders and care plans, and to document refusals, but confirmed the omission of the neck pillow from the care plan. This lack of comprehensive care planning placed the resident at risk for unmet care needs and not achieving their maximum practicable level of functioning.
Failure to Provide Ordered Neck Support for Resident with Contractures
Penalty
Summary
A resident with quadriplegia, aphasia following nontraumatic intracranial hemorrhage, and dysphagia following cerebrovascular disease was admitted to the facility and identified as being at risk for contractures, specifically a neck flexion contracture. Physician orders directed staff to apply a neck pillow for head support, and the resident's care plan noted limited range of motion and the need for assistance with activities of daily living. However, there was no documentation in the care plan regarding the neck pillow intervention. Multiple observations over two days revealed that the resident was not provided with the neck pillow, and the device was not present in the resident's room. Staff interviews confirmed that the resident was supposed to have a neck pillow for support, and both the ADON and DON stated that staff were expected to follow physician orders and care plans unless the resident refused, with refusals to be documented. The facility failed to provide the required equipment to prevent further decrease in range of motion, as ordered and care planned.
Failure to Use Hair Restraint During Meal Service
Penalty
Summary
A deficiency was identified when a kitchen aide was observed serving the noon meal in a second-floor dining room without wearing a hair restraint, as required by the facility's Personal Hygiene policy. The policy, dated 12/27/24, specifies that all dining and nutritional services associates must wear a hairnet or beard restraint in food preparation, production, and serving areas to promote personal hygiene and infection control. During the observation, the kitchen aide admitted to forgetting to put on a hair net. The Dietary Manager confirmed that staff are expected to wear hair restraints to prevent hair follicles from contaminating food served to residents. This lapse had the potential to affect 54 residents receiving an oral diet.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Staff failed to adhere to the facility's infection control practices and policies for a resident who was on Enhanced Barrier Precautions (EBP). During wound care and bathing, a Certified Nursing Assistant (CNA) did not wear a gown as required, despite an EBP sign posted on the resident's door indicating the need for gown and glove use during high-contact activities such as bathing and wound care. The Registered Nurse (RN) performing wound care did wear the appropriate personal protective equipment (PPE), but the CNA, who was assisting with positioning the resident and providing a bed bath, did not. The CNA later acknowledged awareness of the EBP requirements but admitted to not wearing a gown during the care activities. The resident involved had significant medical needs, including a stage 4 pressure ulcer, an indwelling urinary catheter, a feeding tube, and severe cognitive impairment. Review of the resident's care plan and medical orders revealed no documentation or orders for Enhanced Barrier Precautions, although the infection prevention nurse maintained a separate list and ensured signage was present. The Director of Nursing confirmed that EBP was not typically documented in the care plan or as a physician order, but expected staff to follow posted EBP instructions.
Failure to Protect Residents from Sexual Abuse by Known Offender
Penalty
Summary
The facility failed to protect four male residents from sexual abuse by another resident with a known history of hypersexual and inappropriate behaviors. Upon admission, the resident's family member informed staff of her history of sexually inappropriate behaviors towards men and requested specific precautions, including restricting her access to male residents' rooms and requesting male staff not provide her care. Despite this information, no care plan was developed to address or alert staff to her hypersexual behaviors. Multiple incidents occurred in which the resident engaged in inappropriate sexual contact with male residents, all of whom had moderate to severe cognitive impairment. These incidents included lying on top of a resident in his bed, kissing and touching his face, slapping another resident on the thigh/groin area, and sitting in the laps of other residents while stroking their faces. Some incidents were reported and investigated, while others were not, with facility leadership determining without proper assessment that the behaviors were consensual and caused no harm. Interviews with staff revealed that they were not informed of the resident's history of inappropriate sexual behaviors, nor were they provided with education or interventions to prevent such incidents or increase supervision. Staff members expressed that they would consider the behaviors to be sexual abuse and would have reported them if they had been aware. The Social Services Director was also not informed of the incidents, and nursing staff did not recognize or report the behaviors as abuse, failing to assess the affected residents for harm or consent.
Failure to Report Alleged Sexual Abuse of Cognitively Impaired Residents
Penalty
Summary
The facility failed to report allegations of sexual abuse involving two male residents who were severely cognitively impaired and unable to consent. According to the facility's policy, all allegations of abuse or those involving serious bodily injury must be reported immediately, but no later than two hours. Despite this, incidents involving inappropriate hypersexual behaviors by a female resident with a known history of such behaviors were not reported to the State Agency. The female resident had a documented history of sexually inappropriate behaviors towards men and was assessed as having moderately impaired cognition. The two male residents involved had severe cognitive impairment, as indicated by their low BIMS scores, making them unable to consent. The Administrator acknowledged that the incidents were reported to her by a registered nurse but were not reported to the State Agency. She stated that the incidents were not recognized as sexual abuse, believed there was no harm, and considered the behavior consensual based on staff input, despite the residents' inability to consent. The Administrator could not provide a rationale for determining consent and did not know which staff member observed the incidents. This failure to report the allegations as required by facility policy and regulatory requirements constitutes the deficiency.
Failure to Investigate Resident-to-Resident Sexual Abuse Allegations
Penalty
Summary
The facility failed to investigate allegations of abuse involving two male residents with severe cognitive impairment after another resident, who had a known history of sexually inappropriate behaviors, was observed engaging in potentially abusive conduct. Specifically, the resident with a history of hypersexual behaviors was seen sitting on one male resident's lap and stroking and rubbing another male resident's face. Both male residents were documented as being severely cognitively impaired and unable to consent, yet no investigation was initiated following these incidents. Staff interviews revealed that the incidents were not recognized as potential abuse, and the administrator stated that no investigation was conducted because the incidents were perceived as consensual and harmless. However, there was no documented assessment to determine the ability of the involved residents to consent or whether any harm had occurred. The facility's own policy required immediate response and investigation of alleged abuse, including assessment of the alleged victims, but these steps were not taken.
Failure to Assess Geri-Chair Use Leads to Accident Hazard
Penalty
Summary
The facility failed to properly assess a resident for the use of a Geri-chair, which resulted in a deficiency related to accident hazards and inadequate supervision. The facility's Fall Management policy requires that each resident's risk for falls be evaluated and that appropriate interventions, including assistive devices, be implemented based on interdisciplinary assessment. However, for a resident with a diagnosis of Myasthenia gravis and a history of unsteady gait and fall risk, there was no documented therapy assessment for the use of a Geri-chair, nor was its use included in the resident's care plan as a fall prevention measure. Multiple staff interviews confirmed that the resident was observed in a Geri-chair on several occasions, and the resident's family member reported frequent falls. The Director of Rehabilitation and the RN supervisor both stated that therapy should assess residents for Geri-chair use, and expressed concerns that using a Geri-chair for a resident who is able to stand could pose an accident hazard. Despite this, the resident was placed in a Geri-chair without a documented therapy assessment or interdisciplinary team involvement. Documentation reviewed, including comprehensive nursing assessments and the care plan, did not reflect any evaluation or plan regarding the Geri-chair as an intervention. The DON indicated that the decision to use the Geri-chair was made by nursing staff for comfort, rather than based on a formal assessment. This lack of proper assessment and care planning for the use of the Geri-chair created the potential for falls and injuries for the resident.
Failure to Timely Complete Physician-Ordered Urinalysis
Penalty
Summary
A resident with a diagnosis of dementia with behavioral disturbance was admitted and later discharged from the facility. During the resident's stay, a grievance was filed indicating that a registered nurse (RN) received an order for a urinalysis (UA) but did not follow through with entering the order into the system. The order was eventually entered and the specimen was sent for stat processing, with results returning negative. However, the delay in entering and processing the UA order was confirmed through interviews and document review. The facility was unable to provide relevant policies when requested. Interviews with the administrator confirmed that the RN had not entered the physician's order as expected, and the nurse practitioner stated that staff are expected to enter and follow physician orders. The failure to timely complete the UA had the potential to delay treatment for abnormal laboratory results.
Failure to Obtain Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that laboratory tests were obtained as ordered by the physician for a resident. The resident, who was admitted with chronic kidney disease, hypertension, atrial fibrillation, chronic right hip pain, gout, and osteoarthritis, had physician orders for several laboratory tests, including a Vitamin D Panel, Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), and Uric Acid level, to be conducted every six months. Despite these orders, there was no evidence in the clinical record that the blood samples for these tests were obtained. The facility's Administrator confirmed that the laboratory service did not draw the samples, and the facility did not follow up to ensure the laboratory tests were completed.
Failure to Assess and Document Pressure Ulcers
Penalty
Summary
The facility failed to ensure thorough and routine assessment of pressure ulcers for two residents, R8 and R9. R8 was admitted with multiple diagnoses including type 2 diabetes mellitus and chronic kidney disease. On 3/30/2024, a nurse noted a blister on R8's heel with purple discoloration, indicating a potential pressure ulcer. Despite initial treatment and notification of the physician, the ulcer was not measured or staged, and no further assessments were conducted until 4/19/2024, when it was identified as a Deep Tissue Injury (DTI). The treatment continued without further assessments until R8 was hospitalized, and there was no additional wound tracking documentation. R9, admitted with paraplegia and type 2 diabetes mellitus, had a wound on the left ankle upon admission. On 5/20/2024, it was assessed as a stage 2 pressure ulcer, and treatment orders were documented. However, after 6/21/2024, no further assessments were recorded, although treatment continued. An observation on 7/10/2024 confirmed the presence of a stage 2 pressure ulcer with a granulation wound base and bloody drainage. Interviews with the Regional Nurse Consultant and Treatment Nurse BB revealed a lack of consistent wound assessment and documentation. Treatment Nurse BB admitted to not measuring R8's wound weekly, believing it was not necessary, and confirmed the absence of further assessments for R9's wound after 6/21/2024. This lack of routine assessment and documentation contributed to the deficiency in pressure ulcer care for both residents.
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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.
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Nursing homes near Albany
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth - Palmyra | 1.2 mi | ★★★★★ | 8 | 0 |
| Lee County Health And Rehabilitation | 9.8 mi | ★★★★★ | 0 | 0 |
| Pruitthealth - Sylvester | 19.9 mi | ★★★★★ | 0 | 0 |
| Dawson Health And Rehabilitation | 20.4 mi | ★★★★★ | 5 | 0 |
| Archbold Living Camilla | 25.1 mi | ★★★★★ | 6 | 2 |
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