Wilkes Regional Medical CTR SN

In the surveyor’s words

From the most serious findings on record at Wilkes Regional Medical CTR SN, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Apr 23, 2025

  Based on observations and staff interviews, the facility failed to: (1) remove expired items from 1 of 1 reach in cooler; (2) provide an open/ use by date for food available for use in 1 of 1 walk in refrigerators and 2 of 2 walk in freezers; (3) maintain dishware that was stacked wet and available for use; and (4) keep dishes free from dried debris available for use. This deficient practice had the potential to affect eight (8) of eight (8) residents. The findings included: a. On [DATE] at 11:45 AM with the Kitchen Supervisor, one half gallon of whole milk was observed with an expiration date of [DATE] and was available for use in the reach in cooler. b. Observation of the kitchen occurred on [DATE] at 11:45 AM with the Kitchen Supervisor. […]

• No harm, potential for more than minimal, patternF814Apr 23, 2025

  Based on observation and staff interviews, the facility failed to keep the area around the garbage compactor free of accumulated trash and debris for 1 of 1 garbage compactor observed. The findings included: An observation was completed on of the garbage compactor area on 4/21/2025 at 12:40 PM. The observation revealed the following items outside of the garbage compactor: 1 medium black plastic bag of trash, multiple blue latex gloves, 1 tin can, 2 dented hazard cones, 1 empty syringe, 1 small container of unidentified food. A large gray bag of trash and large brown box was sitting on the loading dock where the garbage compactor was located. An interview with the Kitchen Supervisor on 4/21/2025 at 1:00 PM revealed the garbage compactor was used by the whole hospital. […]

• No harm, potential for more than minimal, patternF880Apr 23, 2025

  Based on record review and staff interviews, the facility failed to implement an infection surveillance plan for monitoring and tracking infections in the facility. This practice had the potential to affect 8 of 8 residents in the facility. Findings included: The facility's Infection Prevention and Control Surveillance policy dated 2/1/25 documented the Infection Preventionist (IP) conducts surveillance of all infections among residents and partners including tracking and analysis of outbreaks of infections. Record review indicated Resident #2 receiving antibiotics for osteomyelitis and Resident #4 receiving antibiotics for a wound infection. The Infection Preventionist (IP) nurse was interviewed on 4/23/25 at 9:15 AM. […]

• No harm, potential for more than minimal, patternF883Apr 23, 2025

  Based on record review and staff interviews, the facility failed to document education was provided in the medical record regarding the benefits and potential side effects of the influenza and pneumonia vaccines. This occurred for 3 of 5 residents (Resident #210, Resident #110, and Resident #159) reviewed for vaccines. The findings included: a. Resident #210 was admitted to the facility on [DATE]. The admission Minimum Data Set assessment dated [DATE] showed the resident to be cognitively intact. The resident's immunization record was reviewed and revealed that flu vaccine was current, but the resident was due the pneumonia vaccine and Resident #210 had declined the pneumonia vaccine. […]

• No harm, potential for more than minimal, patternF887Apr 23, 2025

  Based on record review, resident, and staff interviews, the facility failed to document that education was provided in the medical record regarding the benefits and potential side effects of the COVID-19 vaccines. This occurred for 4 of 5 residents reviewed for immunizations (Resident #210, Resident #110, Resident #159, Resident #4). The findings included: a. Resident #210 was admitted to the facility on [DATE]. The admission Minimum Data Set assessment dated [DATE] showed the resident to be cognitively intact. The Resident's immunization record was reviewed and revealed that the resident had declined the covid vaccine. The immunization record review also revealed that nothing was documented under the education notes section on the immunization record for this vaccine. […]