Wallace Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Wallace Rehabilitation and Healthcare Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF880Apr 14, 2021

  Based on observation, staff interviews, and record reviews, the facility staff failed to ensure one of one staff members (Dietary Aide #2) wore their facial covering over their mouth and nose while working in the facility and one of one staff members (Dietary Aide #1) wore a cloth mask not authorized by the facility. The failures occurred during a COVID-19 pandemic. Findings included: 1. Facility records indicated an in-service was conducted on 03/09/21. The in-service was provided to all staff members/departments and educated staff on use of Personal Protective Equipment (PPE). Another in-service was also conducted on 03/31/21 on the use of N95 and face shields. During the initial tour of the kitchen on 04/05/21, Dietary Aide #1 (DA#1) was observed wearing a cloth mask. […]

• No harm, potential for more than minimal, isolatedF695Feb 8, 2024

  Based on record review, observations and staff interviews, the facility failed to place signage indicating oxygen was in use outside resident rooms for 2 of 3 residents reviewed for oxygen use (Resident #228 and Resident # 69). Findings included: 1. Resident #69 was admitted to the facility on [DATE], and diagnoses included congestive heart failure. Resident #69 was discharged from the facility on 1/27/2024 to the hospital and was readmitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #69 was cognitively intact, was not experiencing shortness of breath and was not receiving oxygen therapy. […]

• No harm, potential for more than minimal, isolatedF867Sep 23, 2022

  Based on staff interview and record review, the facility Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor these interventions the committee put into place following the 04/14/2021 recertification survey. This was for a recited deficiency in the area of infection control. This deficiency was cited again on the current recertification survey. The continued failure during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. […]

• No harm, potential for more than minimal, isolatedF880Sep 23, 2022

  Based on record review, observation and staff interviews, the facility failed to ensure staff followed the facility's infection control procedures by not performing hand hygiene when donning and doffing Personal Protective Equipment (gloves) during wound care for 1 of 1 resident observed for pressure ulcer wound care (Resident #60). The findings included: Review of the facility's Infection Control: Hand Hygiene policy, released January 2022, read in part, Effective hand hygiene reduces the incidence of healthcare associated infections . B. Indications for Hand Hygiene Using Alcohol-based Hand Sanitizer include: #7 Before donning gloves; #8 After removing gloves . An observation of Resident #60's wound care was conducted on 09/22/22 at 9:42 a.m. […]

• No harm, potential for more than minimal, isolatedF550Apr 14, 2021

  Based on observation, record review, staff and resident interviews the facility failed to maintain dignity by failing to knock on doors or ask permission to enter for 3 of 6 residents (Resident #32, Resident #26 and Resident #33). Findings included: 1. Resident #32 was admitted to the facility on [DATE]. The most recent quarterly Minimum Data Set (MDS) dated [DATE] had Resident #32 coded as moderately cognitively impaired with the ability to express his ideas and wants. During an observation of the 300 Hall breakfast pass on 04/05/2021 at 8:19 AM, NA #1 was seen walking into Resident #32's room with a food tray without knocking and waiting to enter. […]