Wilkinson Residential Health Care Facility

In the surveyor’s words

From the most serious findings on record at Wilkinson Residential Health Care Facility, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF755May 27, 2025

  Based on observation, record review, and interview conducted during a recertification survey, the facility did not ensure control and accountability, determine that drug records were in order, that an account of all controlled drugs was maintained and periodically reconciled. Specifically, (a.) a count was not completed prior to narcotic access keys being handed from one licensed nurse to another; (b.) nursing staff did not document nursing unit narcotics as having been counted by two licensed nurses and signed at the beginning and end of each shift on the facility-provided Controlled Substance Count Sheets for three (3) of three (3) nursing units; and (c.) the facility did not complete periodic reconciliation of controlled substance records. […]

• No harm, potential for more than minimal, patternF600May 27, 2025

  Based on record review and interviews conducted during the recertification and abbreviated survey (Case #s NY00343349, NY00344172, NY00345225, and NY00379263), the facility did not ensure the resident's right to be free from abuse and neglect for three (3) (Resident #s 40, 44, and 53) of eight (8) residents reviewed for abuse and neglect. Specifically, (a.) on 6/02/2024, Resident #40 was left unattended outside of the facility by Certified Nurse Aide #7 for an extended period of time; (b.) on 6/12/2024, Certified Nurse Aide #8 did not follow Resident #44's care plan to use a mechanical lift which resulted in an injury to the residents foot; (c) on 5/27/2025, Certified Nurse Aides #'s 5 and 6 did not provide personal care to Resident #53 the way the resident preferred, causing Resident #53… […]

• No harm, potential for more than minimal, patternF689May 27, 2025

  Based on record review, observation, and interview conducted during a recertification and abbreviated (Case #NY00377111) survey , the facility did not ensure that resident environments were as free from accidents or hazards as was possible for three (3) (Resident #s 40, 44, and 358) of five (5) residents reviewed for accidents and hazards. Specifically, (a.) Resident #40, who was at risk for elopement and required supervision, was left alone outside unsupervised for 98 minutes on [DATE], and unable to get back into the building; (b.) an expired ointment medication was left on the Resident #44 ' s bedside table on [DATE], permitting access to the ointment by the resident or anyone that entered the room; and (c.) for Resident #358 - who was documented as someone who wandered with significant… […]

• No harm, potential for more than minimal, patternF695May 27, 2025

  Based on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure that each resident received the necessary respiratory care and services that followed professional standards of practice, the resident's care plan, and the resident's choice for three (3) (Resident #'s 44, 63, and 79) of five (5) residents reviewed for oxygen administration. Specifically, (a.) supplemental oxygen flow rate was not ordered by the physician for Resident #'s 44 and 63; (b.) for Resident #79 oxygen therapy was not monitored and physician orders were not followed for cleaning and maintaining respiratory therapy equipment according to professional standards of practice. […]

• No harm, potential for more than minimal, patternF656Aug 9, 2022

  Based on observation, record review, and interviews during a recertification survey dated 08/03/2022 through 08/09/2022, the facility did not ensure comprehensive care plans (CCP) were developed and implemented for each resident consistent with the resident rights and that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs for 5 (Resident #'s 9, 43, 71, 74, and #83) of 24 residents reviewed. Specifically, for Resident #9, whose primary language is Spanish and whose English proficiency is limited, the facility did not ensure their comprehensive care plan included a plan for the resident to communicate effectively, for Resident #43, the facility did not ensure the CCP for a suprapubic catheter included monthly changes of… […]