Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before 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 Winslow House Care Center during CMS and state inspections, most recent first.
A resident who required substantial/maximal assistance for transfers and was identified as a fall risk was being moved from bed to a shower chair using a full body mechanical lift operated by two CNAs. After the sling was raised, the CNA operating the lift activated the leg-spreading function, assumed the legs were fully opened based on the usual grinding noise, and then backed and turned the lift. Because the lift legs were not fully spread, the lift became imbalanced, tipped to one side, and the wheels lifted off the floor, causing the resident to be lowered to the ground while still attached to the lift. The lift’s crossbar struck the resident’s eyebrow, resulting in a bruise, and the resident also sustained a small skin tear on the toe, as documented by nursing staff.
The facility failed to maintain an effective QAPI process to identify and correct a previously cited infection control deficiency. A prior survey had found that staff did not use Enhanced Barrier Precautions during care for at-risk residents, and a later complaint and incident survey again cited the same issue under F880. The Administrator reported that she monitors and audits QAPI effectiveness and confirmed the ongoing concern about the repeated infection control deficiency, with 47 residents in the facility at the time.
A resident with multiple comorbidities, severe cognitive impairment, and a Stage III pressure ulcer on the left lateral foot had a physician order for daily evening-shift wound care, including cleansing, betadine application, and foam dressing with gauze wrap. After a visit to a wound provider, the resident’s wound dressing remained dated from that appointment, and the resident reported that wound care had not been done for at least one night. A PT note and incident report documented that the dressing had not been changed as ordered, while an LPN had signed the treatment record indicating wound care was completed on several days, later admitting he had not performed the dressing change and had signed it off because the wound clinic had changed the dressing. An RN subsequently confirmed the outdated dressing and completed the overdue treatment, revealing a failure to provide and accurately document wound care as ordered.
A resident with multiple comorbidities, severe cognitive impairment, and a stage 3 pressure ulcer had a care plan requiring Enhanced Barrier Precautions (EBP), including gown and glove use for high-contact care, PPE availability at the room entrance, and door signage indicating required precautions. During an observed wound dressing change, an RN performed the entire procedure without donning a gown, and the room lacked both PPE signage and available PPE. The RN later stated she forgot to wear the gown and noted the absence of signage after the resident’s recent room change, despite facility policy directing gown and glove use for wound care under EBP.
Staff failed to consistently document the administration and inventory of controlled medications, resulting in discrepancies between medication counts, delivery records, and the Medication Administration Record. In several cases, staff administered narcotics without immediate documentation, and incomplete records prevented accurate tracking of controlled substances for multiple residents with pain management needs.
The facility failed to update care plans for two residents, one with schizophrenia and another with hearing impairment. The care plan for the resident with schizophrenia lacked goals and interventions related to the diagnosis, while the resident with hearing impairment reported inadequate staff accommodation for her needs. Staff interviews revealed unclear responsibilities for updating care plans.
A resident requiring gastric tube medication administration experienced deficiencies in care when medications were given late without physician notification, an extended-release tablet was crushed, and Enhanced Barrier Precautions were not followed. The RN failed to wear a protective gown during the process, contrary to facility policy.
Improper Mechanical Lift Use Leads to Resident Fall and Minor Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe use of a full body mechanical lift during a bed-to-chair transfer, resulting in a fall with injury for one resident. The resident had no cognitive impairment, required substantial/maximal assistance for transfers, and had diagnoses including heart failure, diabetes, and a left heel pressure ulcer. The resident was care planned as a fall risk, with directions for staff to use a full body lift with two staff for transfers to a shower chair. On the day of the incident, two CNAs used a brand-name full body mechanical lift to transfer the resident from bed to a shower chair. During the transfer, staff reported that after raising the resident in the sling, the CNA operating the lift pressed the control to separate the lift’s legs and heard the usual grinding noise, then assumed the legs had fully opened. She then backed the lift away from the bed and began to turn it toward the shower chair. As the lift was turned, it began to lean to one side, and the wheels lifted from the floor. Staff accounts and subsequent checks indicated that the legs of the lift had not been fully opened, causing imbalance and tipping of the lift while the resident was suspended. As the lift tipped, one CNA attempted to hold the lift and another attempted to support and lower the resident. The lift’s crossbar struck the resident’s eyebrow, causing a bruise measuring 2.5 cm by 1 cm, and the resident also sustained a skin tear on the lateral side of the right great toe measuring 1 cm by 0.5 cm. The resident was found on the floor on her back with knees bent, still attached to the lift, which was on its side. The resident reported that the machine tipped over while staff were transferring her. Staff and nursing assessments documented the bruise to the forehead and the skin tear to the toe, which healed within a few days, and the resident denied pain, headache, or nausea following the incident.
Repeated Infection Control Deficiency Due to Ineffective QAPI Process
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective Quality Assurance Performance Improvement (QAPI) process to identify and correct a previously cited infection control problem. A prior CMS 2567 dated 9/25/2025 documented a deficiency for staff failure to use Enhanced Barrier Precautions during resident care for residents identified as at risk. During a subsequent complaint and facility-reported incident survey on 1/28/2026, surveyors again identified the same infection control deficiency under F880, indicating that staff continued not to use Enhanced Barrier Precautions as required for at-risk residents. In an interview on 1/28/2026, the Administrator stated that she monitors and audits the effectiveness of the QAPI process and acknowledged the concern about the repeated pattern of the F880 deficiency. The facility had a reported census of 47 residents at the time of the current survey.
Failure to Complete and Accurately Document Ordered Wound Care Treatment
Penalty
Summary
The deficiency involves the facility’s failure to complete ordered wound treatment for a resident with a documented Stage III pressure ulcer on the left lateral foot. The resident’s MDS showed diagnoses including heart failure, diabetes, non-Alzheimer’s dementia, vascular disease, and a Stage III pressure ulcer, with severe cognitive impairment (BIMS score 5/15) and a need for staff assistance with ADLs. The care plan directed staff to assess the pressure ulcer and surrounding skin weekly and to complete treatments as ordered. A physician order dated 11/17/25 specified that staff were to cleanse the foot wound and surrounding skin, paint the callous and wound with betadine, cover with a foam dressing, and secure with gauze wrap and tape, to be completed daily on the evening shift. On 12/16/25, the resident attended a local wound provider appointment and returned without new orders. A progress note from the wound provider on that date documented that the wound appeared worse, with increased dimensions, and described the diabetic left lateral wound as clean, painful, and fragile, present for more than a year. On 12/18/25, a physical therapy treatment note documented that the resident stated wound care had not been completed the previous night and that the wound cover was still dated 12/16 from the wound doctor appointment; the Administrator was notified. An incident report from the same date recorded that the Administrator was informed that the dressing on the resident’s left foot had a past date and had not been changed on the evening shift, and that when the day nurse went to change the dressing, the resident reported that no one had changed the dressing for a couple of days. Review of the December 2025 treatment record showed that an LPN (Staff K) had signed off the wound treatment as completed on 12/15, 12/16, and 12/17, placing his initials with a check mark indicating completion. In a subsequent interview, Staff K admitted he forgot to do the dressing change on the day the resident went to the wound clinic, could not recall the exact date, and stated he had just signed it off because the wound clinic had done the dressing change that day. He further stated that he did not make any progress notes regarding the wound and reported that everyone else did it that way on days a resident went to the wound clinic. The DON and ADON reported becoming aware of the issue when the resident was found on 12/18/25 with a dressing dated 12/16/25, and an RN confirmed observing the dressing dated 12/16 and completing the scheduled dressing change on her shift because it had apparently not been done as ordered on 12/17. The facility’s medication administration policy required staff to administer medications as prescribed and to sign the medication administration record after administration, underscoring that documentation should reflect actual completion of ordered treatments.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not utilizing Enhanced Barrier Precautions (EBP) for a resident requiring wound care. The resident had diagnoses including heart failure, diabetes, non-Alzheimer’s dementia, vascular disease, and a stage 3 pressure ulcer, and required substantial assistance with toileting and bathing and partial assistance with ambulation. The MDS showed a BIMS score of 5/15, indicating severe cognitive impairment. The resident’s care plan, dated 9/8/25, specified the need for EBP due to a wound, with goals to reduce the spread of infectious agents and minimize transmission of infection. Interventions directed staff to wear a gown and gloves for high-contact activities, keep PPE available near the room entrance, maintain signage on the door indicating required precautions and PPE, and practice good hand hygiene. On observation, the resident’s bedroom door lacked PPE signage and the room did not have PPE available for staff use. A RN entered the room to perform a daily dressing change and, contrary to the EBP requirements and facility policy, did not don a disposable gown while assembling supplies, elevating the resident’s foot, removing a soiled dressing with a dark substance, measuring the wound, performing the wound treatment, and re-dressing the wound. The RN acknowledged in interview that she did not wear a gown as required and attributed this to forgetting, noting the absence of a sign on the door and that the resident had recently changed rooms. The Assistant DON later stated that the resident had recently changed rooms and that staff must not have brought the sign and PPE to the new room. Review of the facility’s Transmission Based Precautions policy, updated 4/1/24, confirmed that EBP requires staff to don gowns and gloves prior to high-contact care activities such as wound care for any skin opening requiring a dressing.
Failure to Accurately Account for and Document Controlled Medications
Penalty
Summary
The facility failed to maintain an accurate inventory and proper documentation of controlled medications for multiple residents. For several residents with significant pain management needs and complex medical histories, staff did not consistently document the administration of controlled substances on the Medication Administration Record (MAR) or the Controlled Substance Shift Count and Usage Record. In several instances, staff signed out medications on the count sheet but failed to record the administration on the MAR, and in some cases, the facility could not provide complete records for medication deliveries and usage. There were also discrepancies between the number of doses delivered, the number remaining, and the documentation provided. Observations revealed that staff did not always sign out narcotics at the time of administration, leading to inconsistencies between the physical count of medications and the documented records. For example, empty medication packs were found when records indicated doses should remain, and staff admitted to administering medications without immediately documenting them. In one case, a medication cassette was found to contain a Tylenol tablet instead of the prescribed controlled substance, and the facility's investigation confirmed the discrepancy. Staff interviews confirmed lapses in documentation and adherence to procedures for handling and recording controlled substances. The facility's policies required immediate documentation of controlled substance administration and mandated that two staff members verify and sign off on narcotic counts at shift changes. However, these procedures were not consistently followed, as evidenced by incomplete records, missing documentation, and staff admissions of failing to sign out medications as required. These failures resulted in an inability to accurately account for controlled medications received, dispensed, and administered to residents.
Care Plan Deficiencies for Residents with Schizophrenia and Hearing Impairment
Penalty
Summary
The facility failed to ensure comprehensive care plans were reviewed and revised in a timely manner for two residents. Resident #27, diagnosed with schizophrenia, had a care plan that lacked goals, triggers, and interventions related to this diagnosis. Despite the resident's confirmation of having schizophrenia for a long time, the care plan only included focus areas for Asperger's Syndrome, schizoid personality disorder, and depression. The resident's progress notes did not document the new diagnosis or any communication with the provider or discussion with the resident for care planning. Staff interviews revealed a lack of clarity on responsibility for updating care plans, with the MDS Nurse Coordinator relying on information from the Director of Nursing. Resident #25, diagnosed with Meniere's disease and unspecified hearing loss, reported that staff did not accommodate her hearing needs adequately. The care plan included an intervention to ensure the resident's glasses were in good repair but lacked documentation related to her hearing, hearing aid care, goals, or interventions. The resident expressed dissatisfaction with the staff's communication regarding her hearing needs. A nurse consultant acknowledged the need for care plans to be reviewed and updated to reflect the residents' needs.
Medication Administration and EBP Failures
Penalty
Summary
The facility failed to adhere to professional standards of medication administration for a resident requiring medications via gastric tube. The resident, who was on NPO status and required tube feeding, had medications scheduled for 8:00 AM. However, these medications were administered late, and the physician was not notified of the delay as required by the facility's policy. Additionally, an extended-release tablet was crushed, which is against standard medical practice, and this error was not questioned or clarified with the physician. During the medication administration process, the registered nurse did not follow Enhanced Barrier Precautions (EBP) as she failed to wear a protective gown, despite being aware of the requirement. This oversight was acknowledged by the nurse and confirmed by the facility's Director of Nursing and Administrator designee. The facility's policy and training materials clearly outlined the necessity of wearing a gown and gloves when caring for residents with gastric tubes, which was not adhered to in this instance.
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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.
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Nursing homes near Marion
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oakview Nursing & Rehablitation - Marion | 0.8 mi | — | 1 | 0 |
| Terrace Glen Village | 1.3 mi | — | 5 | 0 |
| Silver Oak Nursing And Rehabilitation Center Llc | 1.7 mi | — | 4 | 0 |
| Linn Manor Care Center | 2.6 mi | — | 10 | 0 |
| Hallmar Village | 2.6 mi | — | 11 | 0 |
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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.