Waters of Wakarusa Skilled Nursing Facility, The

In the surveyor’s words

From the most serious findings on record at Waters of Wakarusa Skilled Nursing Facility, The, in the surveyor’s own words.

• Immediate jeopardy, isolatedF622Jan 8, 2025

  Based on record review and interview, the facility failed to ensure a notice of discharge was provided in writing, discharge planning was completed, and a resident's discharge was safe with continuity of care ensured for 1 of 3 residents reviewed for discharge. (Resident E) This deficient practice resulted in an unsafe discharge when the resident was transferred to a hospital waiting area without admission arrangements and no way to obtain nutrition through enteral feedings. The resident voiced feeling of hopelessness and felt others wanted him to die. The immediate jeopardy began on 12/24/24 when the facility discharged Resident E to a hospital waiting area. The Administrator and Regional Administrator were notified of the immediate jeopardy at 3:58 P.M. on 1/6/25. […]

• No harm, potential for more than minimal, widespreadF812Mar 14, 2025

  Based on observation, record review, and interview, the facility failed to store food under sanitary conditions related to foods not tightly sealed and outdated foods, for 1 of 1 kitchen observed. This issue had the potential to affect 83 of 83 residents who received food from this kitchen. Findings include: On [DATE] at 9:39 A.M., a kitchen tour was conducted with [NAME] 2. The following was observed in the walk-in cooler: - An opened bag of sausage gravy with a use by date of [DATE]. - An opened container of ketchup with no use by date. - An opened bag of tomato soup with a use by date of [DATE]. - An opened bag of lettuce not sealed tightly. - An opened bag of shredded cheddar cheese not sealed tightly. - An opened bag of lettuce with a use by date of [DATE]. […]

• No harm, potential for more than minimal, widespreadF812Jan 8, 2025

  Based on observation, interview and record review, the facility failed to ensure hot food and cold liquids were served and maintained in a sanitary and safe manner related to staff touching food and other items both with the same gloved hands during meal service and not keeping room tray meal cart food at the proper serving temperature during two random food service observations. (Main Kitchen and ICF/Maple Unit) This had the potential to affect all residents who received food and drinks from the kitchen. Findings include: 1. During dinner service on 1/3/25 at 5:30 P.M. - 5:33 P.M., the following was observed from the entrance to kitchen: The Dietary Manager (DM) and Dietary Aide 28 were in the kitchen wearing blue gloves which covered their hands. […]

• No harm, potential for more than minimal, patternF684Mar 14, 2025

  Based on observation, interview and record review the facility failed to follow a Physicians order to hold a hypotensive medication (Resident 24), failed to keep a complete hospice binder (Resident 55), failed to follow physician's orders regarding hypertensive medication (Resident 6), failed to provide recommended emollient for skin (Resident 39), and failed to provide sliding scale insulin for 2 day for a resident with diabetes mellitus (Resident 331). Finding includes: 1. The record for Resident 24 was reviewed on 3/12/2025 at 9:43 A.M. […]

• No harm, potential for more than minimal, patternF803Mar 14, 2025

  Based on observation and interview, the facility failed to ensure recipes were followed when preparing pureed meals. This deficient practice had the opportunity to affect 4 of 4 residents who received pureed meals from the kitchen. Finding includes: During an observation of the preparation of pureed meals on 3/10/2025 at 11:41 A.M., [NAME] 2 added 4 scoops of cauliflower and an unmeasured amount of water to the mixer. She indicated she used a #8 (1/2 cup) scoop for the cauliflower and added as much water as she needed to get the correct consistency. [NAME] 2 did not use a recipe for the pureed cauliflower. During an observation of the main dining on 3/10/2025 at 12:29 P.M., Resident 14 received a pureed meal. […]