Wynhoven Community Care Center

In the surveyor’s words

From the most serious findings on record at Wynhoven Community Care Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF678Apr 17, 2025

  Based on interviews and record reviews, the facility failed to ensure an effective system was in place to ensure the resident record accurately reflected a resident's wishes for a code status of Do Not Resuscitate (DNR) if an emergency occurred for 1 (Resident #103) of 46 (Resident #1, Resident #4, Resident #5, Resident #10, Resident #11, Resident #14, Resident #19, Resident #20, Resident #23, Resident #24, Resident #25, Resident #28, Resident #29, Resident #33, Resident #35, Resident #36, Resident #37, Resident #39, Resident #40, Resident #41, Resident #46, Resident #52, Resident #53, Resident #60, Resident #61, Resident #68, Resident #71, Resident #72, Resident #76, Resident #77, Resident #80, Resident #82, Resident #83, Resident #85, Resident #86, Resident #87, Resident #88, Resident… […]

• Actual harm, isolatedF689Mar 30, 2026

  Based on interviews, observations, and record reviews, the facility failed to ensure a resident's enabler bar was not an accident hazard for 1 (Resident #1) of 3 sampled residents reviewed for accident hazards. This deficient practice resulted in actual harm on 02/28/2026 at 7:33PM for Resident #1, when S3Certified Nursing Assistant (CNA) transferred Resident #1 from her wheelchair to the bed. Resident #1's left leg hit the enabler bar, with a missing end cap, which resulted in a laceration to Resident #1's left lower leg. […]

• No harm, potential for more than minimal, patternF755Apr 17, 2025

  Based on interview and record reviews, the facility failed to implement their controlled substance policy to ensure controlled drugs were reconciled for 1 (Medication Cart b) of 3 (Medication Cart a, Medication Cart b, Medication Cart c) medication carts reviewed for reconciliation of controlled substances. Findings: Review of the facility's Controlled Substances Policy and Procedure, revised on 10/06/2023, revealed, in part, nursing staff must count controlled medications at the end of each shift. Further review revealed the nurse coming on duty and the nurse going off duty must make the count together and discrepancies must be documented and reported to the Director of Nursing. […]

• No harm, potential for more than minimal, patternF880Apr 17, 2025

  Based on observations, interviews, and record reviews, the facility failed to ensure staff wore proper personal protective equipment (PPE) for a resident on Enhanced Barrier Precautions (EBP) during a resident transfer and linen change for 3 (S10Certified Nursing Assistant [CNA], S11CNA, S12CNA) of 4 (S10CNA, S11CNA, S12CNA, S15CNA) CNAs observed while providing care to residents on EBP. Findings: Review of the facility's Enhanced Barrier Precautions policy and procedure dated 2001 and revised on 04/2024, revealed, in part, EBP should be followed when working with residents when close physical contact would occur during transfer and mobility. Further review revealed personnel should use gowns and gloves if they were changing the linens of residents on EBP. […]

• No harm, potential for more than minimal, patternF656Apr 11, 2024

  Based on record reviews, observations, and interviews, the facility failed to ensure a resident who no longer resided on a locked memory care unit's careplan was updated for 2 (Resident #9 and Resident #71) of 2 residents reviewed for Dementia Care. Findings: Review of the facility's undated document titled, Memory Care Unit Transition to Wander Guard System document revealed, in part, all residents transitioning from the memory care unit to a wander guard would have their careplan updated. Resident #9 Review of Resident #9's electronic medical record (EMR) revealed, in part, Resident #9 was admitted to the facility on [DATE] with a diagnosis of Dementia and Alzheimer's Disease. […]