Inspection Reports for Winder Center for Nursing and Healing
263 E May St, Winder, GA 30680, GA, 30680
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 12, 2024, found no deficiencies after a revisit survey confirmed correction of prior issues. Earlier inspections showed a mix of findings, including an Immediate Jeopardy related to pressure ulcer care identified in October 2024, which was resolved during that survey period. Main deficiencies involved pressure ulcer prevention and treatment, documentation of advanced directives, blood glucose monitoring, and some life safety code issues such as emergency lighting and sprinkler system maintenance. Complaint investigations were mostly unsubstantiated, with one substantiated case related to pressure ulcer care that coincided with the Immediate Jeopardy finding. The facility appears to have addressed prior deficiencies effectively, as recent follow-up and complaint-related surveys found no outstanding issues.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
49% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
145 residents
Based on a December 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Deficiencies: 0
Date: Dec 12, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Winder Center for Nursing and Healing following a regulatory survey.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 145
Deficiencies: 0
Date: Dec 12, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the October 18th, 2024, Recertification and Complaint Survey.
Findings
All deficiencies cited in the prior October 18th, 2024 survey were found to be corrected during this revisit survey.
Inspection Report
Abbreviated Survey
Census: 145
Deficiencies: 0
Date: Dec 12, 2024
Visit Reason
An Abbreviated Partial/Extended Survey was conducted to investigate multiple complaints identified by codes GA00253106, GA00253103, GA00252722, GA00252412, and GA00253089.
Complaint Details
The survey was complaint-related, investigating complaints GA00253106, GA00253103, GA00252722, GA00252412, and GA00253089. No deficiencies were found related to these complaints.
Findings
No deficiencies were cited for any of the complaints investigated during the survey.
Report Facts
Complaints investigated: 5
Facility census: 145
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 2, 2024
Visit Reason
A Follow-Up Survey was conducted as a desk review to verify correction of previously cited survey tags.
Findings
All previously cited survey tags have been corrected as noted during the follow-up survey.
Inspection Report
Renewal
Deficiencies: 1
Date: Oct 18, 2024
Visit Reason
The inspection was a Licensure Survey conducted from September 24, 2024 through October 18, 2024 to assess compliance with licensure requirements for the facility.
Findings
The facility failed to provide necessary care to prevent the development and worsening of pressure ulcers for one resident (R145), including failure to perform weekly skin assessments and provide recommended treatment for a sacral pressure ulcer. Immediate Jeopardy was identified and removed during the survey period.
Deficiencies (1)
Failure to provide necessary care and services to prevent development and worsening of pressure ulcers for resident R145, including failure to ensure weekly skin assessments and wound observations and failure to provide recommended treatment for a sacral pressure ulcer.
Report Facts
Wound measurements: 7
Wound measurements: 13
BIMS score: 4
Dates: Feb 16, 2024
Dates: Oct 10, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN TTT | Licensed Practical Nurse | Nurse on record who signed CNA bath sheet but did not recall being told about sacral wound |
| CNA HH | Certified Nursing Assistant | Reported skin issues during bathing and communication practices |
| Corporate Wound Nurse EE | Corporate Wound Nurse | Described wound care procedures and documentation practices |
| Wound Care Nurse LPN FF | Wound Care Nurse | Described responsibilities for treatment orders and bath sheet handling |
| Wound Nurse Practitioner SSS | Wound Nurse Practitioner | Documented unstageable sacral wound and planned treatment |
| NP JJJ | Nurse Practitioner | Documented wound culture, condition changes, and treatment orders |
| Former Wound Care Nurse VVV | Former Wound Care Nurse | Stated responsibility for entering orders as per Wound NP |
| DON | Director of Nursing | Stated no specific knowledge of concerns regarding resident R145 and described wound care nurse responsibilities |
Inspection Report
Complaint Investigation
Census: 142
Deficiencies: 5
Date: Oct 18, 2024
Visit Reason
A standard survey was conducted from 9/24/2024 through 10/18/2024, investigating multiple complaint intake numbers related to the facility's compliance with Medicare/Medicaid regulations.
Complaint Details
Multiple complaints were investigated, with some substantiated with deficiencies related to pressure ulcer care and other issues. Immediate Jeopardy was identified related to pressure ulcer care for resident R145.
Findings
The facility was found noncompliant with Medicare/Medicaid regulations, including Immediate Jeopardy related to pressure ulcer care for resident R145, failure to document advanced directives accurately, failure to provide required Medicare notices, failure to follow care plans for skin assessments, failure to monitor blood glucose properly for a diabetic resident, failure to provide adequate pressure ulcer prevention and treatment, and failure to obtain physician orders for colostomy care for resident R396.
Deficiencies (5)
Failure to follow care plan for skin assessments and pressure ulcer treatment for resident R145, resulting in an unstageable sacral wound and subsequent septic shock.
Failure to ensure advanced directive was accurately documented for resident R397.
Failure to provide Notice of Medicare Non-Coverage and Skilled Nursing Facility Advance Beneficiary Notice to residents R94 and R397.
Failure to ensure professional standards for blood glucose monitoring for resident R146 receiving insulin.
Failure to obtain physician order for colostomy care for resident R396.
Report Facts
Resident census: 142
Skin assessments completed: 131
Staff educated: 27
Staff educated: 43
Staff educated: 6
Pressure ulcer measurements: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN FF | Wound Care Nurse | Responsible for wound care and education on pressure ulcer prevention |
| CNA GG | Attended in-service training on reporting and documentation of skin changes | |
| LPN MMM | Administered insulin to resident R146 and commented on missing fingerstick orders | |
| LPN TTT | Nurse on record who signed CNA bath sheet for resident R145 | |
| CWN EE | Corporate Wound Nurse | Described wound care procedures and responsibilities |
| DON | Director of Nursing | Confirmed education and oversight of wound care and skin assessments |
| NP JJJ | Nurse Practitioner | Provided wound care orders and assessments for resident R145 |
| LPN FFF | Provided information on colostomy care for resident R396 |
Inspection Report
Complaint Investigation
Census: 140
Deficiencies: 6
Date: Oct 18, 2024
Visit Reason
The inspection was conducted due to complaints and concerns regarding the facility's compliance with resident care standards, including advanced directive documentation, notification of Medicare non-coverage, care plan implementation for pressure ulcers, blood glucose monitoring, pressure ulcer prevention and treatment, and ostomy care.
Complaint Details
The complaint investigation revealed multiple deficiencies including inaccurate advanced directive documentation, failure to provide Medicare non-coverage notices, failure to follow care plans for pressure ulcers leading to immediate jeopardy, inadequate blood glucose monitoring, and lack of physician orders for colostomy care.
Findings
The facility was found deficient in multiple areas including failure to accurately document advanced directives, failure to provide required Medicare non-coverage notices, failure to follow care plans for pressure ulcer prevention and treatment resulting in immediate jeopardy, failure to monitor blood glucose appropriately for diabetic residents, and failure to obtain physician orders for colostomy care. Corrective actions and education were implemented to remove immediate jeopardy by 10/11/2024.
Deficiencies (6)
Failed to ensure the advanced directive was documented accurately throughout the Electronic Medical Record for one resident.
Failed to provide Notice of Medicare Non-Coverage and Skilled Nursing Facility Advance Beneficiary Notice to residents discharged from Medicare Part A coverage.
Failed to follow the care plan for skin assessments for one resident, resulting in immediate jeopardy due to pressure ulcer development and inadequate wound care.
Failed to ensure professional standards were followed for blood sugar monitoring of one resident receiving insulin.
Failed to provide necessary care and services to prevent development and worsening of pressure ulcers for one resident, including failure to complete weekly skin assessments and wound observations and failure to provide recommended wound treatment.
Failed to obtain a physician order for colostomy care for one resident requiring colostomy services.
Report Facts
Residents reviewed for advanced directive: 40
Residents discharged from Medicare Part A coverage reviewed: 3
Residents reviewed for pressure ulcers: 6
Residents with pressure ulcers reassessed: 5
Residents reviewed for blood glucose monitoring: 7
Residents with colostomy care deficiency: 1
Residents census: 140
Staff educated on pressure ulcer prevention and treatment: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN MMM | Licensed Practical Nurse | Named in blood glucose monitoring deficiency for resident R146 |
| LPN FF | Licensed Practical Nurse | Wound care nurse involved in pressure ulcer care and education |
| CNA GG | Certified Nursing Assistant | Attended in-service training on skin change reporting and documentation |
| DON | Director of Nursing | Confirmed deficiencies and education related to advanced directive, pressure ulcer care, and blood glucose monitoring |
| CMO | Chief Medical Officer | Provided interview on blood glucose monitoring standards and reviewed policies |
| LPN FFF | Licensed Practical Nurse | Named in colostomy care deficiency for resident R396 |
| CNA HH | Certified Nursing Assistant | Described reporting process for skin issues during bathing |
| LPN TTT | Licensed Practical Nurse | Interviewed regarding reporting of skin conditions and wound care responsibilities |
Inspection Report
Complaint Investigation
Census: 140
Deficiencies: 6
Date: Oct 18, 2024
Visit Reason
The inspection was conducted due to complaints and concerns regarding multiple deficiencies including advanced directive documentation, failure to provide Medicare notices, inadequate care plan implementation for pressure ulcers, blood glucose monitoring issues, pressure ulcer care, and colostomy care.
Complaint Details
The complaint investigation revealed multiple deficiencies including failure to document advanced directives correctly, failure to provide Medicare notices, failure to follow care plans for pressure ulcers, inadequate blood glucose monitoring, failure to provide appropriate pressure ulcer care, and failure to obtain physician orders for colostomy care. Immediate jeopardy was identified related to pressure ulcer care but was removed after corrective actions were implemented.
Findings
The facility was found deficient in accurately documenting advanced directives, providing required Medicare notices, following care plans for pressure ulcers, monitoring blood glucose for diabetic residents, providing appropriate pressure ulcer care, and obtaining physician orders for colostomy care. Immediate jeopardy was identified related to pressure ulcer care but was removed after corrective actions.
Deficiencies (6)
Failed to ensure the advanced directive was documented accurately throughout the EMR for one resident.
Failed to provide Notice of Medicare Non-Coverage and Skilled Nursing Facility Advance Beneficiary Notice to residents discharged from Medicare Part A coverage.
Failed to follow the care plan for skin assessments for one resident, resulting in immediate jeopardy.
Failed to ensure professional standards were followed for blood sugar monitoring of one resident receiving insulin.
Failed to provide necessary care and services to prevent development and worsening of pressure ulcers for one resident, resulting in immediate jeopardy.
Failed to obtain a physician order for colostomy care for one resident who required colostomy services.
Report Facts
Residents reviewed for advanced directive: 40
Residents discharged from Medicare Part A coverage reviewed: 3
Residents reviewed for pressure ulcers: 6
Residents reviewed for unnecessary medications: 7
Residents with pressure ulcers reviewed: 6
Residents with colostomy care reviewed: 1
Resident census on 10/10/2024: 140
Residents reassessed for pressure ulcer risk: 139
Staff educated on pressure ulcer prevention and management: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| R397 | Resident | Named in advanced directive documentation deficiency. |
| Director of Nursing (DON) | Director of Nursing | Confirmed advanced directive documentation error and involved in corrective actions. |
| Business Office Manager (BOM) | Business Office Manager | Revealed failure to provide Medicare notices. |
| R145 | Resident | Named in pressure ulcer care deficiencies and immediate jeopardy. |
| Corporate Wound Nurse (CWN) EE | Corporate Wound Nurse | Provided information on wound care procedures and deficiencies. |
| MDS Coordinator RR | MDS Coordinator | Discussed care plan interventions and education. |
| CNA GG | Certified Nursing Assistant | Attended in-service training on skin change reporting. |
| Chief Medical Officer (CMO) | Chief Medical Officer | Provided information on blood glucose monitoring standards. |
| LPN MMM | Licensed Practical Nurse | Admitted missed fingerstick glucose monitoring. |
| LPN FF | Licensed Practical Nurse | Wound care nurse, discussed wound care responsibilities. |
| R146 | Resident | Named in blood glucose monitoring deficiency. |
| R396 | Resident | Named in colostomy care deficiency. |
| LPN FFF | Licensed Practical Nurse | Confirmed lack of colostomy care orders. |
Inspection Report
Life Safety
Census: 143
Capacity: 163
Deficiencies: 5
Date: Oct 3, 2024
Visit Reason
The inspection was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements, including deficiencies in emergency lighting, exit signage, hazardous area enclosures, sprinkler system maintenance, and smoke barrier wall integrity. These deficiencies could potentially affect all residents.
Deficiencies (5)
Two emergency lighting units in the kitchen failed to operate when tested.
Exit signs were not provided on the 700 hall near room 710 and the 400 hall near room 405.
The fuel-fired heater room door in the kitchen area was not provided with a functioning door self-closer.
The sprinkler system was not properly maintained: no general information sign for the dry sprinkler riser and inadequate supply of spare sprinkler heads.
Unsealed penetrations were found in the smoke barrier walls near rooms 202 and 502, and the stairwell near the central hallway.
Report Facts
Census: 143
Total Capacity: 163
Number of emergency lighting units failed: 2
Number of exit sign deficiencies: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff AM and Staff M confirmed findings during the inspection but no full names provided |
Inspection Report
Abbreviated Survey
Census: 141
Deficiencies: 0
Date: Dec 20, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint number GA00241801 from 12/18/2023 to 12/20/2023.
Complaint Details
Complaint number GA00241801 was investigated and found to have no deficiencies cited.
Findings
No deficiencies were cited related to complaint GA00241801 during the survey.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Oct 2, 2023
Visit Reason
The document is a plan of correction related to the facility's failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day period.
Findings
The facility failed to report complete COVID-19 data to the CDC's NHSN between 09/25/2023 and 10/01/2023 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Routine
Census: 100
Deficiencies: 3
Date: Aug 11, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident rights, dignity, privacy, and food service sanitation at the Winder Center for Nursing and Healing.
Findings
The facility failed to maintain resident dignity and privacy by displaying confidential clinical information openly in resident rooms for two residents. Additionally, the facility failed to maintain sanitary conditions in the kitchen, including unclean equipment and unlabeled food items, though most issues were corrected by follow-up.
Deficiencies (3)
Failure to ensure resident dignity by displaying confidential clinical information openly in resident rooms for two residents (R#51 and R#24).
Failure to maintain sanitary conditions of kitchen equipment including ice maker, beverage cooler, mixer, deep fryers, knives, and floors and walls of dry storage area.
Failure to label and date items stored in an upright cooler and dry storage room.
Report Facts
Residents affected: 2
Residents affected: 100
Sample size: 38
Sample size: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Speech Therapist | Placed signs with resident clinical information above beds | |
| Interim Director of Nursing (DON) | Indicated posting signs with resident clinical information is a dignity and HIPAA violation | |
| Assistant Dietary Manager (ADM) | Conducted initial tour and identified kitchen sanitation concerns | |
| Dietary Manager (DM) | Responsible for cleaning schedules and confirmed kitchen sanitation issues | |
| LPN AA | Interviewed regarding placement of signs by Speech Therapist | |
| Dietary Aide DD | Confirmed kitchen staff follow cleaning schedule |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 17, 2019
Visit Reason
The inspection was conducted due to an allegation of verbal abuse by a Certified Nursing Assistant (CNA) toward a resident, which triggered a complaint investigation.
Complaint Details
The complaint involved verbal abuse by CNA AA toward resident R A, including yelling and making disparaging comments. The CNA was suspended and reported to the State Agency. The investigation substantiated the abuse, and the CNA was pending termination. Staff were reeducated on abuse reporting requirements.
Findings
The facility failed to timely report suspected verbal abuse by a CNA toward a resident, which had the potential to affect 46 residents on Unit 1. The investigation confirmed inappropriate verbal behavior by the CNA, who was suspended and pending termination. Additionally, the facility failed to ensure proper labeling and dating of food items and cleanliness of the microwave in resident pantries on two units.
Deficiencies (2)
Failed to timely report suspected verbal abuse by a CNA toward a resident.
Failed to ensure the microwave was clean and that all items in the resident pantry and pantry refrigerator were labeled and dated on two units.
Report Facts
Residents potentially affected: 46
Dates of abuse in-services for CNA AA: 6
Dates of abuse in-services for CNA BB: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA AA | Certified Nursing Assistant | Named in verbal abuse findings and suspension pending termination. |
| CNA BB | Certified Nursing Assistant | Witnessed verbal abuse by CNA AA and was reeducated on abuse reporting. |
| R A | Resident | Victim of verbal abuse by CNA AA. |
| R B | Resident | Witnessed verbal abuse by CNA AA toward R A. |
| R C | Resident | Witnessed verbal abuse by CNA AA toward R A. |
| Administrator | Interviewed regarding abuse allegation, investigation, and staff education. | |
| CNA Supervisor | Interviewed regarding complaint reporting procedures and investigation. | |
| Licensed Practical Nurse CC | LPN | Provided information on employee education and training. |
| Registered Nurse EE | RN | Interviewed about pantry refrigerator and microwave cleanliness. |
| Licensed Practical Nurse FF | LPN | Interviewed about pantry refrigerator and microwave cleanliness. |
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