Communities of Wildwood Ranch

Inspectors wroteBased on record review and interview, the facility failed to ensure all residents were free from unnecessary medications when staff administered blood pressure medication to one resident (Resident #22) when the resident's blood pressure was outside for the physician ordered parameters for administration. Review of the facility's policy titled Clinical Administering Medications, with a revised date of April 2019, showed the following: -Medications are administered in a safe and timely manner, and as prescribed; -Medications are administered in accordance with prescriber orders; [...]

Inspectors wroteBased on interview and record review, the facility staff failed to ensure an environment as free for accident hazards of possible for all residents, when the facility failed to ensure staff were aware of where to find care planned fall interventions and followed care planned fall intervention for one resident (Resident #1) resulting the resident falling from his/her bed, while not in the low position, and left unattended. The fall resulted in facial injuries and skin tears requiring the resident to be sent to the hospital. The facility census was 111. Review of the facility's policy Falls and Fall Risk, revised March 2018, showed the following: -Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents were as free from accident hazards as possible when staff completed a slide transfer for one resident (Resident #1) without ensuring the area was free from potential hazards prior to completing transfer resulting in the resident's leg getting caught in a blanket while being transferred resulting in pain. The facility had a census of 109. Review of a facility policy titled, Safe Lifting and Movement of Residents, revised July 2017, showed the following information: -Nursing staff in conjunction with rehabilitation staff shall assess resident needs for transfer assistance and will document the resident transfer and lift needs in the care plan; -Manual lifting of residents shall be eliminated when feasible. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to implement policies and procedures to help prevent abuse when staff failed to ensure the required criminal background checks (CBC - check that searches for criminal misconduct) for three staff members (Registered Nurse (RN) B, Licensed Practical Nurse (LPN) D, and Social Services (SS) A); employee disqualification list (EDL - list maintained by the Department of Health and Senior Services of individuals who have been determined to have: abused or neglected a resident; misappropriated funds or property belonging to a resident) checks for four staff members (RN B, Office Staff C, LPN D, and Certified Occupation Therapy Assistant (COTA) F); [...]

Inspectors wrote2. Review of Resident #8's face sheet showed the following: -admission date of 06/29/23; -Diagnoses included dependence on acute respiratory failure and pneumothorax (the presence of air or gas in the cavity between the lungs and chest wall, causing collapse of the lung). Review of the resident's discharge MDS, dated [DATE], showed the resident discharged with return anticipated. Review of the resident's progress notes dated 07/24/23, at 1:41 A.M., showed the following: -Night shift 07/23/23 - The resident was sent to the hospital for evaluation due to shortness of breath, diminished lung sounds, edema (swelling), rapid weight gain with history of kidney disease, cardiac disease, and respiratory failure. Staff notified family. Staff notified administrator and physician notified via electronic system. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide protective oversight to all residents to prevent possible accidents/elopements when the staff did not complete checks of wander guards (wander/elopement alarm/devices) as ordered; when the facility failed to ensure the wander guard device alarms alarmed at all panels and pagers; and when staff failed to follow policy to ensure residents were accounted after one resident (Resident #14) exited the building causing the wander guard alarm to sound. The facility had a census of 103. Review of the facility's policy titled, Elopement Precautions/Missing Resident, undated, showed the following: -The facility does not have a special care unit; -In this facility, all exit doors are alarmed; [...]

Inspectors wroteBased on record review and interview, facility staff failed to complete a quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment instrument, completed by facility staff) assessment for four residents (Resident #2, #3, #9, and #24) out of 19 sampled residents, within 14 days from the assessment reference date (ARD). The facility had a census of 91. Record review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, Chapter 2, Assessments for the RAI, showed the following information: -The quarterly assessment is an Omnibus Budget Reconciliation Act of 1987 (OBRA) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type; [...]

Inspectors wroteBased on record review and interview, the facility failed to transmit a Death in Facility Minimum Data Set (MDS, a federally mandated assessment instrument, required to be completed by facility staff for care planning) record within 14 days of a death in the facility for one resident (Resident #6). The facility had a census of 91. Record review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, Chapter 2, Assessments for the RAI, showed the following information: -The Death in Facility Tracking Record consists of demographic and administrative items; it must be completed when the resident dies in the facility or when on leave of absence (LOA); [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to complete a side rail assessment to include a risk/benefit review and alternatives attempted prior to use, and failed to obtain informed consent for the use of side rails for four residents (Resident #29, #67, #95 and #101). The facility failed to complete bed rail measurements for one resident (Resident #95). A sample of 19 were reviewed. The facility census was 91. Record review of a facility policy entitled, Bed Safety (Revised December 2007), showed the following information: -Facility shall strive to provide a safe sleeping environment for the resident; [...]

Inspectors wroteBased on record review and interview, facility staff failed to complete an annual Minimum Data Set (MDS, a federally mandated comprehensive assessment instrument, completed by facility staff) assessment for three residents (Resident #3, #12 and #24) within the required 14 days from the assessment reference date (ARD). A sample of 19 residents was selected for review; the facility had a census of 91. Record review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, Chapter 2, Assessments for the RAI, showed the following information: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff cleaned and maintained a continuous positive airway pressure machine (CPAP - treatment for obstructive sleep apnea (breathing repeatedly stops and starts during sleep), with a hose and mask or nosepiece to deliver constant and steady air pressure) according to professional standards, failed to have a physician's order for a CPAP, failed to have a diagnosis for sleep apnea, and failed to address in the care plan the use of the CPAP for one resident (Resident #310); and failed to ensure staff changed oxygen equipment per professional standards, and failed to address in the care plan the use of oxygen for one resident (Resident #95), out of a sample of 19 residents. The facility had a census of 91. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5% when the facility staff made two errors in 28 opportunities resulting in an error rate of 7.14%. Facility staff failed to administer the correct dose of one medication and failed to administer one inhaler per professional nursing standards and manufacturer's specifications for one resident (Resident #311). The facility census was 91. Record review of the Symbicort (name brand for Budesonide/Formoterol inhaler) manufacturer's website dated April 2019, showed the following information: -This product is used to control and prevent symptoms caused by asthma or chronic obstructive pulmonary disease, (COPD - a lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible); [...]