Wind River Rehabilitation and Wellness

In the surveyor’s words

From the most serious findings on record at Wind River Rehabilitation and Wellness, in the surveyor’s own words.

• Actual harm, isolatedF684Mar 14, 2024

  Based on observation, medical record review, and staff and resident interview, the facility failed to promptly identify and intervene for an acute change in condition for 2 of 4 sample residents (#29, #31) who experienced a change in condition. This failure resulted in actual harm to residents #29 and #31 who experienced changes in condition including limited movement and pain following a fall and did not receive a thorough assessment in a timely manner to assess for injuries based on their signs and symptoms. The findings were: 1. Review of the 2/13/24 significant change MDS assessment showed resident #29 had diagnoses including polyosteoarthritis, non-Alzheimer's dementia, and other chronic pain. The resident received scheduled pain medication and had no pain in the last 5 days. […]

• Actual harm, isolatedF697Mar 14, 2024

  Based on observation, medical record review, staff and resident interview, and review of policies and procedures, the facility failed to adequately treat pain for 1 of 6 sample residents (#29) reviewed for pain management. This failure resulted in actual harm to resident #2 who experienced a change in condition including limited movement and pain following a fall and was not treated for severe pain. The findings were: 1. Review of the 2/13/24 significant change MDS assessment showed resident #29 had diagnoses including polyosteoarthritis, non-Alzheimer's dementia, and other chronic pain. The resident received scheduled pain medication and had no pain in the last 5 days. Review of a provider progress note dated 2/7/24 showed the resident had chronic pain of the right knee and lift hip. […]

• Actual harm, isolatedF600Jul 26, 2023

  Based on observation, staff interview, medical record review, and policy review, the facility failed to protect the residents' right to be free from physical abuse by staff and by a resident for 2 of 6 sample residents (#4, #8). This failure resulted in harm to resident #4 and to resident #8, who showed evidence of psychosocial harm such as crying and shaking. The findings were: 1. Review of the admission record showed resident #4 was initially admitted to the facility on [DATE]. The resident had a brief interview for mental status (BIMS) score of 0 out of 15, indicating the resident was severely cognitively impaired. […]

• No harm, potential for more than minimal, widespreadF812Mar 14, 2024

  Based on observation, staff interview, and review of the 2022 Food Code, the facility failed to store and prepare food in accordance with professional standards related to expired food, hair restraints, and hand hygiene/gloving during 3 of 3 observations in the kitchen and 1 of 1 observation of tray line service. The findings were: 1. The following concerns were identified related to hair restraints: a. Observation on [DATE] at 3:15 PM in the kitchen revealed the certified dietary manager (CDM) was wearing a hair restraint, but was not wearing a beard restraint to cover his beard. b. Observation on [DATE] at 12:21 PM revealed the CDM was assisting staff with tray line service (putting sour cream on the trays in the carts) and was not wearing a beard restraint to cover his beard. c. […]

• No harm, potential for more than minimal, widespreadF921Mar 14, 2024

  Based on observation and staff interview, the facility failed to ensure a safe environment for residents, staff, and public. The census was 56. The findings were: 1. Observation on 3/12/24 at 4:40 PM showed broken floor tiles outside the soiled utility room near room [ROOM NUMBER]. The area had built-up dirt and debris in the tile cracks which appeared black in color. In addition, the hand rails in the area were discolored and the sealant had been worn away, which created a porous surface, and the rails could not be effectively sanitized. 2. Observation on 3/12/24 at 4:43 PM showed an EZ Way sit to stand mechanical lift positioned in the hallway, outside room [ROOM NUMBER]. The lift had dirt and debris built-up on the standing platform which appeared black in color. 3. […]