Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Winder Center For Nursing And Healing during CMS and state inspections, most recent first.
A resident with multiple diagnoses and severe cognitive impairment was at risk for pressure ulcers, but the facility failed to follow the care plan for skin assessments. Despite a physician's order for weekly assessments, documentation ceased after a CNA reported an open area on the sacrum. The lack of follow-up led to an unstageable wound, highlighting a significant deviation from the facility's care plan policy.
A resident at risk for pressure ulcers developed a sacral wound that was not properly assessed or treated, leading to a severe deterioration in their condition. Despite facility policies requiring weekly skin assessments, these were not consistently completed, and the recommended treatment for the wound was not implemented. Communication and documentation failures among staff contributed to the resident's condition worsening to septic shock, resulting in hospitalization.
A facility failed to accurately document a resident's advanced directive in the EMR. The resident, with multiple diagnoses and a BIMS score indicating cognitive intactness, had a POLST form signed for DNR status. However, the care plan inaccurately listed the code status as FULL CODE. This error was confirmed by the DON and the resident.
The facility failed to provide the required NOMNC and SNF ABN to two residents discharged from Medicare Part A coverage. One resident remained in the facility, while the other returned home. The Business Office Manager indicated that new Social Services and Therapy employees did not provide these documents upon discharge.
A facility failed to monitor blood glucose levels for a diabetic resident receiving insulin, as there were no specific orders for glucose monitoring upon admission. Despite daily insulin administration, no glucose monitoring was documented until the resident was transferred to the hospital with an altered mental status. Interviews revealed a lack of communication and oversight in ensuring blood glucose monitoring was conducted, as per professional standards.
A facility failed to obtain a physician order for colostomy care for a resident with a history of ulcerative colitis and intestinal obstruction. Despite the facility's policy requiring a licensed nurse to determine the type of ostomy and collaborate with the attending physician, the resident's EMR and MAR lacked orders for colostomy care. Interviews with the DON and an LPN confirmed the absence of these orders, leading to inadequate care management for the resident, who was at risk for skin breakdown.
Failure to Follow Care Plan for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to adhere to the care plan for a resident, identified as R145, who was at risk for pressure ulcers. R145 was admitted with multiple diagnoses, including encephalopathy due to subdural hematoma, chronic kidney disease, and cerebrovascular accident with hemiplegia. The resident was cognitively impaired and dependent on staff for all activities of daily living. The care plan for R145, dated 11/29/2023, included interventions for daily skin assessments, keeping the skin dry, and monitoring nutrition. However, the facility did not follow through with these interventions, as evidenced by the lack of documented skin assessments after 2/16/2024, despite a physician's order for weekly skin assessments. On 2/16/2024, a CNA reported an open area on R145's sacrum to an LPN, but there was no documented follow-up or additional skin assessments recorded in the medical record. The facility's failure to document and address the skin condition led to the development of an unstageable wound on the sacrum, which was identified by a Wound Nurse Practitioner on 3/27/2024. This oversight in care and documentation was a significant deviation from the facility's policy on comprehensive, person-centered care plans, which should include measurable objectives and timetables to meet the resident's needs. Interviews with facility staff revealed a lack of adherence to the care plan and communication breakdowns. The Corporate Wound Nurse indicated that CNAs are responsible for examining the skin during bathing and reporting changes to the unit nurse, while the MDS Coordinator emphasized the importance of following care plan interventions. Despite these protocols, the facility's staff did not consistently perform or document the required skin assessments, contributing to the resident's deteriorating condition.
Removal Plan
- R145 was discharged from the facility to the hospital for a septic wound and did not return to the facility.
- An AD-HOC meeting was held with the Administrator, Director of Nursing, Regional Director of Operations, Regional Director of Clinical Operations, and Chief Medical Officer to address the concerns identified related to the Immediate Jeopardy Citations.
- The RDO, RDCO, and CMO reviewed the center policy on Developing a Comprehensive Care Plan. No policy changes or recommendations were made because of this review.
- A Root Cause Analysis of the wound management system breakdown was completed by RDO, RDCO, CMO, Administrator and DON. Documentation of analysis was put on the RCA Tool and was included in the Ad Hoc Quality Assurance Performance Improvement QAPI meeting. The Root Cause for the immediate jeopardy was identified as staff not following the center's policy for Pressure Ulcer Prevention and Management secondary to education deficit.
- All residents had a pressure ulcer risk assessment performed. Care plans were reviewed and updated by the MDS Coordinators for 139 of 140 residents to ensure that the weekly skin check was listed as an intervention under the at-risk skin care plan.
- The center MDS Coordinator, Wound Care Nurse, and Regional Wound Care Specialist conducted an audit for 5 of 5 residents with pressure ulcers/injuries to ensure that all residents have a comprehensive wound care plan that is being implemented.
- Nursing employees, 6 of 7 RN's, 27 of 29 LPN's and 43 of 46 CNA's were educated by the RWCS, Staff Development Coordinator, and DON on implementation of the care plan for pressure ulcer prevention and management including location of the care plan in the electronic health record and viewing the care plan prior to the start of the shift. LPNs were educated regarding following physicians orders and the person-centered care plan. Any staff not educated during the initial education will have the education prior to the start of their shift or during the orientation period.
- Review of the root cause analysis showed LPNs and CNAs were educated to ensure weekly skin assessments will be completed on a weekly basis and documented. DON will ensure the completion of assessments in a timely manner. The DON verified the DON in-serviced staff along with RN PP. The DON stated CNAs were re-educated on how to fill out shower sheets (and give a copy to the charge nurse and DON), as soon as a skin condition was identified and to notify the nurse immediately.
- Review of a Daily Census revealed 139 of 140 residents were reassessed for risk for pressure ulcers and that residents had a care plan to include weekly skin assessments. This was verified by review of the pressure ulcer risk assessments and care plans for R12, R395, R400, R402 and R403.
- Review of the pressure Ulcer/Injury Care Plan Update Tool revealed 5 of 5 residents care plans were reviewed for accuracy of wound location and care plan reflective of care provided. Review of five residents, R12, R395, R400, R402 and R403, showed the residents had comprehensive care plans for pressure ulcers.
- Review of in-service sign in sheets revealed 27 of 29 LPNs, 43 of 46 CNA's and 6 of 7 RN's were in-serviced by the RWCS on care plans for pressure ulcer prevention and management.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development and worsening of pressure ulcers for a resident, identified as R145. The resident was admitted with diagnoses including encephalopathy due to subdural hematoma, chronic kidney disease, and cerebrovascular accident with hemiplegia. The resident was at risk for pressure ulcers but had none at the time of the initial assessment. However, an open area on the sacrum was reported by a CNA on 2/16/2024, but there was no documented follow-up or treatment for this wound. The facility's policy required weekly skin assessments and documentation of any pressure injuries, but these were not consistently completed for R145. The last documented skin assessment was on 3/1/2024, and there was no mention of a sacral wound. Despite a CNA reporting the sacral wound, it was not documented or treated until it was identified as an unstageable wound by a Wound NP on 3/27/2024. The recommended treatment by the NP was not implemented, and the wound worsened significantly, leading to the resident's hospitalization. Interviews with staff revealed a breakdown in communication and documentation processes. The LPN on duty did not recall being informed about the sacral wound, and the wound nurse was not notified in a timely manner. The facility's system for reporting and documenting skin issues was not followed, contributing to the resident's condition deteriorating to septic shock and necessitating hospitalization.
Removal Plan
- An Ad-Hoc meeting was held with the Administrator, Director of Nursing, Regional Director of Operations, Regional Director of Clinical Operations, and Chief Medical Officer to address the concerns identified related to the Immediate Jeopardy Citations.
- The RDO, RDCO, and CMO reviewed the facility policy regarding Pressure Ulcer Prevention and Management. Facility did not make any policy changes or recommendations on this review.
- A Root Cause Analysis regarding the pressure ulcer prevention and skin management system was completed by RDO, RDCO, CMO, Administrator and DON. Documentation of the RCA was put on the RCA Tool and was included in the Ad-Hoc Quality Assurance Performance Improvement meeting. The Root Cause for the immediate jeopardy was identified as staff not following the center's policy for Pressure Ulcer Prevention and Management secondary to education deficit.
- The facility Unit Managers and Wound Care Nurse conducted skin assessments on 131 of 140 residents residing in the center. Audit revealed no new in-house acquired pressure ulcers/injuries.
- Five of five residents residing in the center identified with pressure ulcers/injuries were reassessed including measurements and documented on by the wound care nurse practitioner.
- Orders were verified for five of five Residents with pressure injuries by the Regional Skin Management Specialist to ensure orders in the electronic medical administration record matched the recommendations of the wound care nurse practitioner. The facility implemented an audit conducted by the DON after each wound care nurse practitioner visit to ensure the orders match the recommendations of the wound care nurse practitioner. This audit will be conducted once a week.
- Nursing employees 6 out of 7 registered nurses, 27 out of 29, licensed practical nurses and 43 out of 46 certified nursing assistants were educated by the Regional Wound Care Specialist Staff Development Coordinator, and DON on the pressure ulcer prevention and treatment. Specifically, CNAs received education to notify the licensed nurse anytime a new skin area was identified and to document the findings on the body sheet. The LPNs/RNs received education on conducting weekly skin assessments and notifying the Medical Provider or Wound Care Nurse Practitioner anytime a new skin area is identified as well as following physician orders and plan of care for wound care treatments. Anyone that was not educated during the Initial education sessions will be educated prior to start of their shift or during the orientation process.
- The Regional Skin Management Specialist educated three of three wound care nurses on ensuring pressure wounds are measured weekly and are assessed on the Weekly Wound Assessment Tool.
- 139 of 140 residents' charts were audited the DON will ensure staff have an order to perform a weekly skin check.
- The facility implemented a process to ensure that skin checks are monitored daily to ensure completion. The DON will conduct daily audits to ensure skin checks are completed daily and to ensure any newly identified pressure ulcer was reported to the MD or Wound Care Provider and an appropriate treatment ordered.
Inaccurate Documentation of Advanced Directive in EMR
Penalty
Summary
The facility failed to ensure the accurate documentation of an advanced directive in the Electronic Medical Record (EMR) for a resident, identified as R397. R397 was admitted with multiple diagnoses, including Sepsis, Chronic Diastolic Heart Failure, Acute Kidney Failure, Respiratory Failure with Hypoxia, Psoriatic Arthritis, and Hyperlipidemia. The resident was cognitively intact, as indicated by a BIMS score of 13. A POLST form dated 7/24/2024, signed by R397 and medical personnel, indicated a code status of Allow Natural Death - Do Not Attempt Resuscitation (DNR). However, the care plan dated 9/24/2024 inaccurately documented the resident's code status as FULL CODE. This discrepancy was confirmed by the Director of Nursing during an interview, and the resident also confirmed the correct DNR status during a separate interview.
Failure to Provide Required Medicare Notices
Penalty
Summary
The facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to two residents who were discharged from Medicare Part A coverage. Resident 94 was discharged from Medicare Part A skilled services and remained in the facility, while Resident 397 was discharged and returned home. There was no documented evidence that these notices were provided to either resident or their responsible parties. During an interview, the Business Office Manager revealed that the facility did not provide the necessary documents to the residents. The manager attributed this failure to the fact that the Social Services and Therapy employees were new to the facility and did not provide the documents upon discharge from Medicare Part A skilled services.
Failure to Monitor Blood Glucose in Diabetic Resident Receiving Insulin
Penalty
Summary
The facility failed to ensure professional standards were followed for blood glucose monitoring of a resident receiving insulin. The facility's policy on Blood Glucose Monitoring did not include a protocol for residents receiving insulin, and there was no documentation of blood glucose monitoring for the resident in question. The resident, who had a diagnosis of diabetes mellitus, was admitted with orders for insulin Glargine but without specific orders for blood glucose monitoring. Despite receiving insulin daily, there was no evidence of glucose monitoring from the time of admission until the resident was transferred to the hospital. The resident was transferred to the hospital due to an altered mental status, where they were diagnosed with a complicated urinary tract infection. Interviews with facility staff revealed a lack of clarity and communication regarding the need for blood glucose monitoring. The Chief Medical Officer stated that blood sugars should be monitored daily for residents on long-acting insulin, even if not specified in hospital discharge orders. However, the Licensed Practical Nurse and the Director of Nursing indicated that the omission of fingerstick orders was an oversight, and the admission nurse failed to clarify the need for such orders with the Nurse Practitioner.
Failure to Obtain Physician Order for Colostomy Care
Penalty
Summary
The facility failed to obtain a physician order for colostomy care for a resident who required such services. The facility's policy on ostomy care mandates that a licensed nurse should determine the type of ostomy through physical assessment and collaboration with the attending physician as part of the comprehensive assessment and care planning process. However, the resident's Electronic Medical Record (EMR) and Medication Administration Record (MAR) lacked any physician orders for colostomy care, including the necessary supplies and frequency for changing the colostomy drainage bag. This oversight was confirmed during interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN), who acknowledged the absence of the required orders on the MAR. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14, had a history of ulcerative colitis and intestinal obstruction, and was at risk for skin breakdown due to the colostomy. The resident reported having to clean the stoma multiple times, indicating a lack of proper care management. The care plan initiated for the resident included colostomy care every shift and as needed, but without the necessary physician orders, the care was not documented or administered as required. This deficiency highlights a gap in the facility's adherence to its own policies and procedures for ostomy care management.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 55 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Winder
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park Place Nursing Facility | 12.5 mi | — | 0 | 0 |
| Mesun Health And Rehabilitation Center | 14.6 mi | — | 9 | 0 |
| University Nursing & Rehab Ctr | 16.3 mi | — | 0 | 0 |
| Presbyterian Village - Athens | 16.6 mi | — | 1 | 0 |
| High Shoals Health And Rehabilitation | 16.8 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Winder Center For Nursing And Healing.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.