Wilson's Creek Nursing & Rehab

In the surveyor’s words

From the most serious findings on record at Wilson's Creek Nursing & Rehab, in the surveyor’s own words.

• Actual harm, isolatedF600Jul 20, 2021

  Based on record review and interview, the facility failed to ensure all residents were free from abuse when one staff member (Certified Nurse Aide (CNA) Q) used curse words when speaking to one resident (Resident #107). The facility census was 133. Record review of facility's policy titled Abuse, Neglect, Exploitation, and Misappropriation, undated, showed the following: -Every nursing home resident has the right to quality care and quality of life including freedom from neglect, abuse, exploitation, and misappropriation of property; -Abuse is deliberate infliction in injury, unreasonable confinement, intimidation, or punishment which results in physical harm, pain, mental anguish. This also includes verbal, sexual, physical, or mental abuse as well as abuse through technology. […]

• No harm, potential for more than minimal, widespreadF812Nov 30, 2023

  Based on observation, interview, and record review, the facility failed to ensure the kitchen ceiling, walls, floors, appliances, and dishware were clean and in good repair, failed to handle left-overs appropriately, and failed to date foods after opening. This deficient practice had the potential to affect 128 of 128 residents who received meals prepared in the facility's only kitchen. The facility census was 128. Review of the facility policy titled, Basics for Handling Food Safely, dated 08/13, showed the following: -Leftovers- Place food into shallow containers and immediately put in the refrigerator or freezer for rapid cooling; -Hot food should be held at 140 F or warmer; -Cold food should be held at 40 degrees F or colder. […]

• No harm, potential for more than minimal, patternF756Nov 30, 2023

  Based on interview and record review, the facility failed to ensure monthly medication regimen reviews (MRR) were completed in a timely manner for five of five sampled residents (Residents #104, #33, #34, #90, and #89) reviewed for unnecessary medications. The facility census was 128. 1. Review of Resident #104's Resident Face Sheet, undated, found in the electronic medical record (EMR) under the Continuity of Care (CCD) Tab, showed the following: -admitted [DATE]; -Diagnoses included major depression, anxiety, and post-traumatic stress disorder (PTSD- mental health condition that's triggered by a terrifying event - either experiencing it or witnessing it. Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event). […]

• No harm, potential for more than minimal, patternF758Nov 30, 2023

  Based on interview and record review, the facility failed to monitor for side effects and target behaviors for three residents (Resident #33, #34, and #104) of five sampled residents reviewed for unnecessary medications and who received psychotropic medications. The facility census was 128. 1. Review of Resident #104 Resident Face Sheet, undated, found in the electronic medical record (EMR) under the Continuity of Care (CCD) Tab, showed the following: -admitted [DATE]; -Diagnoses included major depression, anxiety, and post-traumatic stress disorder (PTSD - makes one feel stressed and afraid after the danger is over). […]

• No harm, potential for more than minimal, patternF584Jul 20, 2021

  Based on observation and interview, the facility failed to maintain a clean, comfortable, and homelike environment when there were urine odors on the special care unit (SCU - locked memory unit); floor tiles in one shared resident bathroom were stained and smelled of urine; and a hot water faucet did not work in one resident's room (Resident #85) room. The deficient practice had the potential to affect all residents who lived on the SCU. The facility census was 133. 1. Observations beginning on 7/12/21, beginning at approximately 9:15 A.M., showed upon entering the SCU a strong urine odor around the nurses' station and on the resident hallways. Observation on 7/12/21, at approximately 10:00 A.M., of resident room C119 (SCU) showed the resident's sheets had been stripped from his/her bed. […]