Inspection Reports for Winder Center for Nursing and Healing
263 E May St, Winder, GA 30680, GA, 30680
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Inspection Report
Deficiencies: 0
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
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
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.
Findings
No deficiencies were cited for any of the complaints investigated during the survey.
Complaint Details
The survey was complaint-related, investigating complaints GA00253106, GA00253103, GA00252722, GA00252412, and GA00253089. No deficiencies were found related to these complaints.
Report Facts
Complaints investigated: 5
Facility census: 145
Inspection Report
Follow-Up
Deficiencies: 0
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
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.
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 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. | Immediate Jeopardy |
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
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.
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.
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.
Severity Breakdown
Immediate Jeopardy: 1
Level D: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| 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. | Immediate Jeopardy |
| Failure to ensure advanced directive was accurately documented for resident R397. | Level D |
| Failure to provide Notice of Medicare Non-Coverage and Skilled Nursing Facility Advance Beneficiary Notice to residents R94 and R397. | Level D |
| Failure to ensure professional standards for blood glucose monitoring for resident R146 receiving insulin. | Level D |
| Failure to obtain physician order for colostomy care for resident R396. | Level D |
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
Life Safety
Census: 143
Capacity: 163
Deficiencies: 5
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.
Severity Breakdown
D: 4
E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Two emergency lighting units in the kitchen failed to operate when tested. | D |
| Exit signs were not provided on the 700 hall near room 710 and the 400 hall near room 405. | D |
| The fuel-fired heater room door in the kitchen area was not provided with a functioning door self-closer. | D |
| The sprinkler system was not properly maintained: no general information sign for the dry sprinkler riser and inadequate supply of spare sprinkler heads. | E |
| Unsealed penetrations were found in the smoke barrier walls near rooms 202 and 502, and the stairwell near the central hallway. | D |
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
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.
Findings
No deficiencies were cited related to complaint GA00241801 during the survey.
Complaint Details
Complaint number GA00241801 was investigated and found to have no deficiencies cited.
Inspection Report
Plan of Correction
Deficiencies: 1
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.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period. | F |
Report Facts
Reporting period: 7
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