Wynfield Park Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Wynfield Park Health and Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF550Jun 20, 2025

  Based on observation, interview, record review, and review of the facility policy titled, Meal Service, the facility failed to provide a dignified dining experience for one of five residents (R)(R45) by standing instead of sitting next to the resident while assisting him during a meal. This failure had the potential to have a negative impact on the quality of life and self-esteem for the affected resident. Findings include: A review of the facility policy titled, Meal Service dated 12/27/24 indicated Associates should promote and maintain patients' dignity and respect during meal service. During a meal observation on 06/17/25 at 12:50 PM, Registered Nurse (RN) 7 was observed standing next to R45 while assisting him with the meal. […]

• No harm, potential for more than minimal, isolatedF600Jun 20, 2025

  Based on staff interviews and record review, the facility failed to protect four of four male residents (R) (R127, R12, R105, and R106) right to be free from sexual abuse by R147. Specifically, the facility failed to protect R127, R12, R105, and R106 from R147s' known inappropriate hypersexual behaviors. Findings include: Review of R147's electronic medical record (EMR), Face Sheet tab, revealed she was admitted on [DATE] with diagnosis that included Encephalopathy, Restlessness and agitation, Disorientation, Delayed milestone in childhood, Unspecified disorder of psychological development, and anxiety disorder. […]

• No harm, potential for more than minimal, isolatedF604Jun 20, 2025

  Based on observation, interview, record review, and review of the facility policy titled, Restraints, the facility failed to ensure one of one Resident (R) (R102) reviewed for physical restraints was not physically restrained by being in bed with a Geri-chair and a regular chair placed up against her bed, blocking her ability to get out of her bed on one side. Findings include: Review of the facility policy titled, Restraints dated 12/27/24 indicated .It is the intent of this center that patients have the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the patient's medical symptoms.Prior to use of a restraint, the following should be completed.Patient's need for restraint assessed.Restraint consent. […]

• No harm, potential for more than minimal, isolatedF609Jun 20, 2025

  Based on staff interviews, record review, and review of the facility policy titled, Abuse Prohibition-Reporting and Investigating, the facility failed to report allegations of sexual abuse for two of four male residents (R) (R106, and R107) reviewed for abuse related to R147's inappropriate hypersexual behaviors. Findings include: Review of the facility's policy titled, Abuse Prohibition-Reporting and Investigating, dated 12/27/24, revealed All allegations of abuse or allegations involving serious bodily injury must be reported immediately but no later than 2 hours. […]

• No harm, potential for more than minimal, isolatedF610Jun 20, 2025

  Based on staff interviews and record review, and review of the facility's policy titled, Abuse Prohibition-Reporting and Investigating, the facility failed to investigate allegations of abuse for two of four male residents (R) (R106, and R107) related to R147's known inappropriate hypersexual behaviors. The facility failed to identify and investigate allegations of resident-to-resident sexual abuse after resident R147 was observed in R106's room and sitting on R106's lap and then stroking and rubbing R105's face. This failure had the potential for additional male residents to be sexually abused by R147. Findings include: Review of the facility's policy titled, Abuse Prohibition-Reporting and Investigating, dated 12/27/24, revealed . […]