Wolf Creek Care Center

In the surveyor’s words

From the most serious findings on record at Wolf Creek Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Dec 8, 2025

  Based on interview and record review, the facility failed to ensure resident safety for two out of six sampled residents (Resident 1 and Resident 2) when:1. Resident 1 left the facility without staff knowledge and was found at a gas station without her Wander Guard (wearable monitoring device that alerts caregivers when a resident leaves a protected area); and2. Resident 2 had an avoidable fall (unintentional fall that happens because of identifiable and correctable factors) when she was not properly secured during transportation to an appointment.This failure resulted in Resident 1 leaving the facility unsupervised and increased her risk for harm and injury and in Resident 2 sustaining a left femur (lower end of thigh bone) fracture (crack, break, or chip in bone) that required surgery. […]

• No harm, potential for more than minimal, widespreadF801May 22, 2025

  Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for a census of 53 residents when the Registered Dietician (RD) and Dietetic Services Supervisor (DSS) were both hired as part time (an employee who is scheduled to work and who does work a schedule of anything under 32 hours per week) employees. This failure had the potential for unsafe food handling and spread of food borne illnesses in a highly susceptible population. Findings: During an interview on 5/19/25 at 9:40 a.m. with the DSS, the DSS stated she was working as a part time employee for the facility and was also working at another facility. […]

• No harm, potential for more than minimal, widespreadF812May 22, 2025

  Based on observation, interview, and record review the facility failed to ensure food storage and preparation, and maintenance of food contact surfaces were in accordance with professional standards for food safety for the 53 residents who ate facility prepared meals when: 1. Three out of three small cutting boards had stains, and two out of six large cutting boards had deep scratches; and, 2. A box of garlic bread, a box of fried eggs, and a box of bacon were found with ice crystals built-up, opened and were exposed to air in the freezer. These failures had the potential to put residents at risk for foodborne illnesses. Findings: 1. […]

• No harm, potential for more than minimal, patternF880May 22, 2025

  Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for one out of 16 sampled residents (Resident 17) when: 1. Resident 17's nebulizer (machine that turns liquid medicine into a mist that can be easily inhaled) face mask was not changed every seven days and was left uncovered when not in use; and, 2. Resident 17's oxygen nasal cannula (a medical device with two prongs that is connected to an oxygen source used to deliver supplemental oxygen directly into the nostrils) was not changed every seven days. […]

• No harm, potential for more than minimal, patternF584Nov 8, 2022

  Based on observation, interview and record review, the facility failed to maintain clean, comfortable, and safe assistive devices needed for daily living for five of fourteen sampled residents (Resident 7, 8, 17, 19 and 45) when their assistive devices (wheelchair) were soiled with food debris and sticky substances. The failure to ensure a safe and sanitary condition of residents' assistive devices resulted in the potential to cause cross contamination between residents from micro-organisms present on the soiled wheelchairs and cushions. Findings: A review of a policy revised 2022, titled, Wheelchair Cleaning, indicated cleaning schedule as follows: All wheel chairs should be cleaned monthly on a weekly schedule when is use and as needed (prn). […]