Wingfield Skilled Nursing and Rehabilitation Cente

In the surveyor’s words

From the most serious findings on record at Wingfield Skilled Nursing and Rehabilitation Cente, in the surveyor’s own words.

• Immediate jeopardy, widespreadF584Mar 31, 2021

  Based on observation, interview, and document review the facility failed to ensure a delayed egress door released immediately when the fire alarm was initiated, impacting the safety and well-being of 87 residents (Resident #32, #402, #44, #26, #33, #65, #25, #62, #63, #42, #58, #64, #15, #22, #51, #408, #55, #30, #405, #37, #47, #18, #16, #27, #23, #46, #18, #16, #27, #23, #46, #61, #401, #49, #36, #39, #6, #400, #8, #59, #406, #54, #19, #17, #34, #38, #12, #320, #45, #321, #41, #410, #29, #403, #20,#28, #409, #52, #35, #53, #31, #48, #21, #40, #319, #56, #379, #60, #43 #381, #382, #14, #24, #317, #66, #50, #57, #380, #318, #367, #407, #368, #369, #370, #371, #372, #373, #374, #375, #376, #377, and #378.) Findings include: An Immediate Jeopardy occurred on 03/24/21 and the facility was… […]

• Immediate jeopardy, widespreadF880Mar 31, 2021

  Based on observation, interview, record review, and document review the facility failed to ensure 1) a resident (Resident #22) experiencing new onset of respiratory symptoms consistent with potential COVID-19 infection was quarantined and evaluated for COVID-19 per Centers for Disease Control and Prevention (CDC) guidelines potentially exposing 48 of the 49 residents on the second floor of the facility to a potentially infectious respiratory disease, 2) staff working in the designated COVID-19 quarantine unit performed hand sanitizing, 3) staff working in the designated COVID-19 quarantine unit used appropriate Personal Protective Equipment (PPE) when entering a resident room, 4) equipment being removed from the COVID-19 quarantine unit was sanitized before entering the designated COVID-19… […]

• Immediate jeopardy, isolatedF689Mar 31, 2021

  Based on interview, record review, and document review the facility failed to 1) report a choking incident, monitor the resident, and refer a resident after a choking incident for 1 of 18 sampled residents (Resident #21) and 2) ensure a resident did not experience a fall for 1 unsampled resident (Resident #11). Findings include: An Immediate Jeopardy occurred on 03/21/21 and the facility was notified on 03/30/21 at 1:05 PM, due to a resident choked and required the [MEDICATION NAME] maneuver. The Physician, Speech Therapist, and the Administrator were unaware of the occurrence. […]

• Actual harm, isolatedF686Dec 14, 2023

  Based on observation, interview, clinical record review, and document review, the facility failed to ensure a bed bound resident with a pressure ulcer was repositioned every two hours and assistive heal protectors were applied correctly, resulting in additional pressure ulcers for 1 of 22 sampled residents (Resident #81). Findings include: Resident #81 Resident #81 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including encephalopathy, unspecified, cognitive communication deficit, muscle weakness, generalized, contracture of muscle, left lower leg, osteomyelitis of vertebra, sacral and sacrococcygeal region, pressure ulcer of sacral region, stage IV, unspecified protein calorie malnutrition, personal history of traumatic brain injury. […]

• Actual harm, isolatedF600Nov 15, 2023

  Based on interview, clinical record review and document review, the facility failed to prevent neglect of a resident when medication was not administered per a physician's order resulting in death for 1 of 31 residents sampled for medication review (Resident #1) and prevent resident to resident abuse for 8 of 8 residents sampled with documented resident to resident altercations (Resident #9, #10, #11, #12, #13, and #14). Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], with diagnoses including cardiac arrest, cause unspecified, and non-ST elevation myocardial infarction (NSTEMI). A hospital Discharge Summary dated [DATE], documented Resident #1 was admitted to the hospital on [DATE] for cardiac arrest. […]