Inspection Reports for
Winslow House Care Center

The complaint investigation found substantiated deficiencies including failure to complete wound care, improper use of mechanical lift causing resident injury, failure to use Enhanced Barrier Precautions, and ineffective QAPI processes.

The facility failed to complete wound treatment as ordered for one resident, failed to properly use a mechanical lift causing a resident fall with injury, and failed to implement effective infection prevention and control measures including Enhanced Barrier Precautions. The facility also had repeated deficiencies related to infection control and quality assurance processes.

The facility was found to have multiple deficiencies related to resident rights, accuracy of assessments, coordination of PASARR and assessments, ADL care, nurse staffing information posting, and infection prevention and control. The facility failed to maintain accurate documentation, provide adequate care in several areas, and comply with infection control protocols. Corrective actions and systemic changes were planned or implemented to address these deficiencies.

The facility failed to maintain code status documentation for a resident, accurately code diagnoses and PASRR assessments, provide adequate bathing care, update daily staffing postings, and implement proper infection prevention and control measures including use of Enhanced Barrier Precautions and PPE.

The investigation was initiated after a medication aide reported that a resident's Hydrocodone/Acetaminophen medication cassette contained Tylenol instead. The facility self-reported the concern to the Department of Inspections and Appeals and conducted an internal investigation, which included police notification. The complaint was substantiated with findings of incomplete medication records and narcotic count discrepancies.

The facility failed to ensure accurate inventory and documentation of controlled medications for four residents, including missing medication administration records and discrepancies in narcotic counts. Staff were re-educated and disciplinary actions were taken, with ongoing audits implemented.

Facility reported incident #126193-I was substantiated. Complaint #126961-C was not substantiated.

The facility failed to ensure accurate inventory and documentation of controlled medications for four residents, with multiple instances of incomplete medication administration records and discrepancies in narcotic counts. The complaint was not substantiated, but the facility was found deficient in maintaining proper controlled substance records and administration procedures.

The facility failed to ensure comprehensive care plans were reviewed and revised timely for 2 of 12 residents, and failed to meet professional standards of medication administration for 1 resident requiring gastric tube medications. Deficiencies were related to care plan content and medication administration practices.

The facility failed to ensure comprehensive care plans were reviewed and revised timely for two residents, and failed to follow professional standards of medication administration for one resident requiring gastric tube medications, including late medication administration without physician notification, crushing extended release tablets, and not following enhanced barrier precautions.

The facility failed to treat residents with dignity during meal assistance and failed to administer medications within the scheduled timeframe for 3 residents. The facility re-educated staff on resident rights, feeding assistance, and medication administration policies and implemented monitoring and auditing procedures.

The complaint investigation substantiated that Resident #200 was pushed in a wheelchair without foot pedals, causing a left ankle fracture. Staff E was disciplined and suspended pending investigation, and the facility reinforced policies on wheelchair safety.

The facility failed to maintain a safe environment free from accident hazards when wheelchair foot pedals were omitted, causing a fracture injury to one resident. Staff education and disciplinary actions were implemented to address the issue.

The facility reported incident #116083-I was substantiated.

The facility was found to have deficiencies related to resident rights and dignity during meals, medication administration outside scheduled times, and failure to ensure wheelchair safety devices were used, resulting in resident injury. Several residents were observed not being treated with dignity and respect, and medication administration times were not consistently met.

The facility failed to treat residents with dignity during meals, administer medications within scheduled time frames, and maintain a safe environment free from hazards, resulting in actual harm to a resident due to a wheelchair transfer incident.

Complaint #112257-C was substantiated. Facility Self-Reported Incident #112308-I was substantiated. Immediate Jeopardy began on April 10, 2023 and was removed on April 19, 2023 after corrective actions were implemented.

The facility failed to ensure adequate supervision and protection of residents, resulting in Resident #2 attempting to suffocate Resident #1 with a pillow and blanket. The facility had a history of resident-to-resident altercations involving Resident #2 and failed to evaluate the effectiveness of interventions. Immediate Jeopardy was identified but removed after corrective actions including 1:1 supervision and care plan updates.

The complaint investigation substantiated that Resident #2 attempted to suffocate Resident #1 on 4/10/2023. The facility was cited for failure to prevent abuse and inadequate supervision. The Immediate Jeopardy was identified on April 10, 2023, and removed on April 19, 2023 after corrective actions were implemented.

The facility failed to prevent resident-to-resident abuse and did not evaluate the effectiveness of interventions to prevent harm. Resident #2, with a history of aggressive behaviors, attempted to suffocate Resident #1, causing immediate jeopardy to resident health and safety. The facility implemented corrective actions including 1:1 supervision and care plan updates.

The complaint investigation substantiated that Resident #2 attempted to suffocate Resident #1 on 4/10/2023. The facility was cited for failure to prevent abuse and inadequate supervision. Immediate Jeopardy was identified on April 10, 2023 and removed on April 19, 2023 after corrective actions were implemented.

The facility failed to prevent resident-to-resident abuse and did not adequately evaluate the effectiveness of interventions to prevent harm. Resident #2, with severe cognitive impairment and a history of aggressive behaviors, attempted to suffocate Resident #1. The facility implemented 1:1 supervision and updated care plans after the incident but lacked documentation of intervention effectiveness prior to the event.

Complaints #108675-C and #109363-C were substantiated. Complaint #107505-C was not substantiated. Facility Self-Reported Incident #109192-I was substantiated. Facility Self-Reported Incidents #108026-I and #109471-I were not substantiated.

The facility failed to provide adequate ADL care including bathing for dependent residents, failed to provide accurate and timely wound care assessment and interventions, failed to ensure residents were safe by preventing falls and responding timely to call lights, and failed to follow infection control guidelines during wound care and resident assistance.

Complaints #99028-C and #100864-C were substantiated as part of this inspection.

The facility was found deficient in documenting review of Skilled Nursing Facility of Beneficiary Notice of Non-Coverage for two residents, failure to meet professional standards in applying tubigrips and insulin pen priming for two residents, failure to maintain a safe environment preventing a fall due to cluttered hallways, and failure to label insulin pens with opening dates.

Complaint #96978 was investigated from 5/24-27/2021 and was substantiated as per the report.

The facility failed to develop and implement a comprehensive person-centered care plan for a resident, failed to hold quarterly Quality Assessment and Assurance (QAA) Committee meetings with required attendance, and failed to establish and maintain an effective infection prevention and control program including proper hand hygiene and laundry handling. Multiple observations and interviews revealed deficiencies in care and infection control practices.

The facility failed to follow CDC recommendations and their own policies to provide a safe and sanitary environment to prevent transmission of COVID-19. Observations and interviews revealed multiple failures in PPE use, hand hygiene, and cleaning protocols, with 12 COVID-19 positive residents and 4 suspected residents identified.

Complaints #92549, #92561, #92581 and Facility Self-Reported Incident #92580 were substantiated.

The facility failed to provide adequate supervision to prevent the elopement of one resident, as evidenced by multiple staff interviews and review of care plans and incident reports. The investigation revealed that door alarms could not be heard in certain resident rooms, contributing to the incident.