Wilton Meadows Health Care Center

In the surveyor’s words

From the most serious findings on record at Wilton Meadows Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF658May 31, 2024

  Based on record review and interviews for one (1) of three (3) residents reviewed for medication errors (Resident #1), the facility failed to ensure that multiple nurses followed the five rights of medication administration in accordance with nursing standards of practice. Resident #1 was administered morphine (an opioid pain medication) at ten (10) times the prescribed dose on three separate occasions resulting in a finding of Immediate Jeopardy. The findings include: Resident #1 was admitted to the facility in April 2024 under palliative care with diagnoses that included cirrhosis, heart failure, chronic kidney disease, and severe sepsis with septic shock. The nursing admission assessment dated [DATE] identified Resident #1 was alert, oriented to person place, time, and situation. […]

• Immediate jeopardy, isolatedF760May 31, 2024

  Based on record review and interviews for one (1) of three (3) residents reviewed for medication administration (Resident #1), the facility failed to ensure the that the resident was free from a significant medication error. Two (2) nurses failed to check the strength/concentration of morphine (an opioid pain medication) prior to administration, and administered the medication at ten (10) times the prescribed dose on three (3) separate occasions, resulting in a finding of Immediate Jeopardy. […]

• Actual harm, isolatedF684Jun 28, 2022

  Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #72) who had an unwitnessed fall, the facility failed to immediately send the resident to the hospital for treatment after the RN assessment demonstrated that the resident was exhibiting pain in the left leg including guarding. Further, the facility failed to adhere to professional standards of practice when staff log rolled the resident onto a sheet and carried the resident down the hall to his/her room approximately 50 feet away to put the resident to bed. […]

• No harm, potential for more than minimal, patternF584May 20, 2026

  Based on observations of the environment, review of facility documentation, review of facility policy/procedures and interviews, the facility failed to ensure the hallways and resident rooms on the 2nd floor were free from foul odors and failed to ensure the water temperatures in the 2nd floor shower room were warm enough to maintain resident comfort in the shower. The findings include:Observations on all days of the survey 5/13, 5/14, 5/18, 5/19 and 5/20/26 identified a foul smell in the 2nd floor hallways. The strongest smell was in the carpeted hallway that contained the main elevators and went down to the dining room. The hallway odor was foul and strong, but the foul odor was also strong in several of the rooms off of that main hallway. […]

• No harm, potential for more than minimal, patternF761May 20, 2026

  Based on observations, review of facility policy/procedures and interviews, the facility failed to ensure expired medications were removed from medication carts and medication rooms. The findings include:Observation of the Birchwood 3 medication cart with LPN #5 on 5/19/26 at 11:46 AM identified 1 full card of Mirtazapine 15 mg (30 pills) expired on 3/11/26.Interview with LPN #5 on 5/19/26 at 11:50 AM identified the pharmacy and the nurses are responsible for checking expiration dates and non-used medications and remove them from the medication cart.Observation of the Birchwood 2 medication cart with LPN #4 on 5/20/26 at 11:29 AM identified the following expired medications: Sertraline 25 mg tabs (8 remaining) expired 5/17/26, Divalproex Sodium 12.5 mg (14 capsules) with a use by date of… […]