Wabasso Restorative Care Center

Inspectors wroteBased on observation, interview, and record review the facility failed to implement appropriate interventions and supervision, monitor and assess changes in mood and mental status, coordinate care with psychiatric providers, and notify the providers of changes in mood/behavior for 1 of 3 residents (R1) who had a significant history of suicidal ideation and suicide attempts. These failures resulted in Immediate Jeopardy (IJ) when R1 attempted suicide after a progressive decline in mood and behavior following the discontinuation of two psychotropic medications without increased monitoring, provider notification, or revision of interventions. Additionally, following R1's return from the hospital, the facility failed to ensure objects that could be used for self-harm were removed or secured despite ordered suicide precautions. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to notify the physician for 1 of 3 residents (R1) reviewed for change of condition.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess continued need of as needed (prn) psychotropic medications for 1 of 3 residents (R2) with provider every 14 days.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow physician orders for 1 of 3 residents (R1) reviewed for weight gain.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure alcohol sanitizing clothes were stored safely out of reach for 1 of 1 resident (R1). The facility's failures resulted in harm for R1 after she obtained alcohol sanitizing/germicidal wipes, placed them in a glass with water, ingested the solution, and required hospitalization with a resulting diagnosis that included acute kidney injury.

Inspectors wroteBased on interview and record review the facility failed to report an injury of unknown origin within the two-hour time period for reporting for 1 of 2 residents (R2) who had an injury of unknown origin of the right tibia (shin bone) and fibula (calf bone).

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure accurate comprehensive assessments for full body mechanical lift slings according to manufacturer's guidelines to ensure safe transfers for 2 of 2 residents (R2, R4) reviewed for accidents. The manufacturer instructions for Sling Selection Guide dated 5/1/26, indicated sling selection to use with the full body lift was determined by both the resident's height and weight. The guide identified it was very important to use the correct sized sling and make sure it was fitted properly prior to lifting. Size small ranged from 75 pounds (lb.) to 150 lbs. with height from 4 feet (ft) 11 inches (in) to 5 ft 4 in, medium sized ranged from 125 lbs. to 200 lbs. with height range of 5 ft 3 in to 5 ft 8 in, large slings from 175 lbs. to 300 lbs. with height of 5 ft 7 in to 6 ft, extra-large slings were from 275 lbs. [...]

Inspectors wroteBased on observation, interview, and document review the facility failed to develop an individualized pain management plan for wound treatments and failed to provide pain management during wound treatment for 1 of 2 residents (R1) reviewed for pain management.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure proper hand hygiene and failed to ensure clean surface are for wound supplies for 2 of 2 residents (R2, R1) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure 1 of 3 residents were free from avoidable accidents from hot liquids. This resulted in actual harm to R1 who spilled hot coffee on her lap and sustained a third-degree burn. In addition, the facility failed to implement a system to assess residents for safety with hot liquids. The facility implemented appropriate corrective action prior to the onsite investigation; therefore, the deficiency is being cited at past non-compliance.

Inspectors wroteBased on interview and document review the facility failed to report an allegation of neglect to the State Agency immediately (2 hours) for 1 of 1 resident (R1) who spilled hot liquid on her upper thigh which result in a significant injury.

Inspectors wroteBased on observation, interview, and document review, the facility failed to appropriately identify, assess, and intervene for 1 of 3 residents (R2) with a change in condition. This caused actual harm when R2 experienced a delay in treatment after developing signs and symptoms of a worsening infection with the potential for sepsis (life-threatening infection) with a known history of infection, who was subsequently transferred to a higher level of care and was hospitalized . The non-compliance that began on 5/4/25 was corrected prior to the survey when the facility implemented corrective action on 8/5/25, to prevent recurrence; therefore, the tag was issued at PAST NON-COMPLIANCE.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the kitchen and dining area was clean and sanitary to prevent cross contamination when preparing and serving food. In addition, the facility failed to ensure the garbage dumpster was securely closed to prevent attracting pests and rodents. This had the potential to affect all 41 residents residing in the facility.

Inspectors wroteBased on observation and interview the facility failed to maintain floor covering in 2 of 2 resident-shared rooms (one room inhabited by R45 and R27 and the other room inhabited by R37 and R51). In addition, the facility failed to ensure the exterior wall in 1 of 1 dining room was maintained in good condition. This had the potential to affect all 41 residents.

Inspectors wroteBased on observation and interview the facility failed to monitor for expired items and appropriately store items in a sanitary manor for 1 of 1 medication room.

Inspectors wroteBased on observation and interview the facility failed to follow appropriate infection control practices when obtaining a blood sugar (BS) level for 1 of 1 resident (R19) while in the dining room. The facility also failed to disinfect 1 of 1 sampled multiple-resident use glucometer. This had the potential to affect all 3 residents seated at the dining table with R19 and 2 other residents who used the multi-resident use glucometer.

Inspectors wroteBased on interview and document review, the facility failed to ensure 2 of 5 (R16 and R21) sampled residents were offered and/or provided updated vaccinations for pneumococcal disease, in accordance with Centers for Disease Control (CDC).

Inspectors wroteBased on interview and document review, the facility failed to investigate a potential crime involving illegal drugs involving 1 of 1 resident (R41).

Inspectors wroteBased on interview and document review the facility failed to notify the responsible party of a hospital transfer for 1 of 4 sampled residents (R7) reviewed for hospitalizations.

Inspectors wroteBased on observation, interview, and document review, the facility failed to revise 1 of 12 sampled resident's (R4) care plan for behaviors.

Inspectors wroteBased on interview, observation, and document review, the facility failed to protect 1 of 1 resident (R1) from resident-to-resident physical abuse.

Inspectors wroteBased on interview and document review, the facility failed to report an allegation of abuse timely to the State Agency (SA) for 1 of 1 resident (R1) reviewed for allegations of abuse.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure both recertification survey results, complaint investigations, and facility plans of correction were available for review. This had the potential to affect all forty-three (43) residents residing in the facility, as well as family, visitors, and staff.

Inspectors wroteBased on interview and document review, the facility failed to ensure residents were informed of medication changes for 1 of 3 residents (R1) reviewed for pharmacy services.

Inspectors wroteBased on interview and document review, the facility failed to notify the resident's physician of multiple missed administrations of an opioid pain medication for 1 of 3 residents (R1) reviewed for pharmacy services.

Inspectors wroteBased on interview and document review the facility failed to ensure resident grievances were provided with a written response for 2 of 4 residents (R1, R3) reviewed for grievances.

Inspectors wroteBased on observation, interview, and document review the facility failed to revise the care plan for wake-up and/or medication administration times for 1 of 4 residents (R4) who demonstrated new behaviors when her medications were not provided in accordance with her preferences.

Inspectors wroteBased on interview and document review, the facility failed to ensure a resident was appropriately assessed and monitored for potential effects of an opioid pain medication that was not administered as ordered for two and a half days for 1 of 3 residents (R1) reviewed for pharmacy services.

Inspectors wroteBased on interview and document review, the facility failed to ensure medications were available to be administered in accordance with physician orders and failed to identify and report a medication error for 1 of 3 (R1) residents reviewed for pharmacy services.

Inspectors wroteBased on interview, observation and document review, the facility failed to ensure adequate supervision and a comprehensive assessment was completed to help prevent resident to resident sexual abuse. As a result of the facilities failures an immediate jeopardy (IJ) situation was identified when resident (R2) wrote unwanted paper notes that were sexual in nature and hand delivered them to R1, resulting in psychosocial harm related to triggering symptoms of PTSD (Post-Traumatic stress disorder) derived from childhood sexual abuse and feelings of insecurity for 1 of 2 residents (R1) reviewed for abuse. The IJ began on 3/27/25 when three residents reported inappropriate behavior by R2, including writing notes that were sexual in natural and touching residents. The facility administrator and director of nursing (DON) were notified of the IJ on 5/22/25 at 4:10 p.m. [...]

Inspectors wroteBased on interview and document review the facility failed to report allegations of abuse timely to the State Agency for 1 of 1 resident (R1) reviewed for allegations of abuse and neglect. The allegations occurred on 3/27/25, 4/2/25, 4/27/25, 5/3/25, and 5/15/25.

Inspectors wroteBased on interview and document review the facility failed to thoroughly investigate and protect residents for an allegation of sexual abuse for 1 of 3 residents (R1) reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to provide 1 of 2 residents (R2) with choices for discharge, right to an appeal process, ability to stay at facility during an appeal process, review and take into account substance use disorder and mental health diagnoses that would impair judgement on the decision to transfer, and allow the resident time to process the discharge prior to discharging. R2's face sheet dated 5/23/25, identified diagnoses of emotional lability (tendency to shift rapidly and dramatically between different emotional states), alcohol use, cognitive communication deficit (challenges with language comprehension, expression, reasoning, attention, memory, and organization), depression, anxiety disorder, and osteonecrosis (death of the bone due to lack of blood supply) to right and left femur. [...]

Inspectors wroteBased on interview, observation and record review, the facility failed to implement trauma-informed care for 2 of 3 residents (R1, R2) identified with a diagnosis of post-traumatic stress disorder (PTSD) reviewed for PTSD-related care.

Inspectors wroteBased on interview and document review, the facility failed to ensure residents who were seen during routine physician visits every 30-60-90 days had physician documentation in the medical record for 1 of 1 (R1) resident, reviewed during the extended survey.

Inspectors wroteBased on interview, observation and document review, the facility failed to implement comprehensive assessment and person-centered planning to ensure residents individualized behavioral health needs were met for 2 of 2 residents (R1, R2) reviewed for behavioral health services.

Inspectors wroteBased on interview and document review, the facility failed to identify specific care or practices necessary to meet identified care needs regarding post-traumatic stress disorder (PTSD). This had the potential to affect all residents currently residing in the facility with a diagnosis or history of PTSD. Furthermore, the facility failed to implement 1 of 1 facility assessment (FA) and ensure the identified number of staff deemed required to provide social services to residents had been maintained. The number of social services designee (SSD) was equal to 1 full time position.

Inspectors wroteBased on observation, interview, and document review, the facility failed to assess 1 of 1 resident (R1) with a known history of substance use/abuse to identify signs and symptoms and potential affects from substance abuse, identify efforts to prevent substance use, and revise his care plan when R1 was found to be intoxicated from alcohol after having been on day-leave from the facility.

Inspectors wroteBased on observation, interview and document review the facility failed to identify a significant change in condition and provide timely medical intervention for 1 of 1 resident (R33) who had increasing, significant weight gain and other symptoms consistent with congestive heart failure (CHF) exacerbation. This resulted in actual harm for R33 when physician orders were not followed and appropriate, timely interventions for significant weight gain were not implemented. R33 was eventually admitted to the local hospital for IV diuretics (medication to remove fluid from the body) caused by CHF exacerbation.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide information to 5 of 5 residents (R1, R9, R15, R26 and R42) who attended the resident council group meeting regarding the Ombudsman services as advocates for residents residing in the facility. This had the potential to affect all 42 residents residing in the facility.

Inspectors wroteR37 R37's admission Minimum Data Set (MDS) assessment identified his cognition was intact, he was independent with activities of daily living (ADLs) and received therapy services of Occupational (OT) and Speech (ST) therapies. R37 also had orders for physical therapy (PT) which he received until the end of August 2024, when the facility no longer had PT services available. R37 had diagnoses of metabolic encephalopathy, alcohol abuse, ADHD, degeneration of his nervous system due to alcohol, cognitive communication deficit, history of falling, weakness, and difficulty walking. R37's current, undated care plan identified he was dependent on staff for meeting emotional, intellectual, physical, and social needs due to his physical limitation. He had MD orders for PT/OT evaluation and treatment. [...]

Inspectors wroteBased on interview and document review the facility failed to ensure the binding arbitration agreement was fully explained in a manner that 16 of 32 residents (R1, R5, R9, R10, R15, R16, R18, R26, R30, R32, R33, R37, R40, R42, R148, and R246) and/or their representatives understood and had been explained their right to not sign the agreement. This had the potential to affect all 32 residents.

Inspectors wroteBased on observation, interview and document review the facility failed to implement enhanced barrier precautions for 1 of 1 resident (R148) who had surgical wounds and a PICC line. Additionally, the facility failed to have appropriate infection control surveillance to monitor infections through to resolution for 3 of 3 months reviewed. This had the potential to affect all 32 residents.

Inspectors wroteBased on interview and document review the facility failed to implement policies to ensure there was no fear of retaliation for 2 of 2 residents (R37 and R40) in addition to some resident council members who also voiced fear of retaliation from facility staff.

Inspectors wroteR5's 10/27/24, quarterly Minimum Data Set (MDS) assessment identified he was cognitively intact with diagnoses of stroke, heart failure, renal insufficiency, diabetes, anxiety, and depression. R5's care plan identified he was a smoker. The goal was that he would not suffer injury from unsafe smoking practices through the review date. Staff were to notify the charge nurse immediately if it is suspected he had violated the facility smoking policy. R5 was able to smoke independently. Interview on 11/12/24 at 10:45 a.m., with R5 identified he was a smoker and kept his cigarettes in a unlocked drawer in his room. He identified that he used to have a locked drawer but that someone took the key that he had hung on the back of his wheelchair before going to bed at night, so he now keeps them in an unlocked drawer. R5 identified staff had never asked him to turn in his lighter. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure the required number of staff determined by their facility assessment had been scheduled and maintained on the weekends.

Inspectors wroteBased on interview and document review the facility failed to ensure 5 of 6 nursing staff were competnet to identify an emergent change in condition and the need to transfer to hospital for emergency medical evaluation for 1 of 1 resident (R33). The facility also failed to follow the facility assessment and/or develop policies and procedures and ensure staff had demonstrated competencies to perform care for residents.

Inspectors wroteBased on observation, interview, and document review, the facility failed to follow up on a verbal grievance for 1 of 1 resident (R5). R5's 10/27/24 quarterly Minimum Data Set (MDS) assessment identified his cognition was intact and had diagnosis of stroke, heart failure, renal insufficiency, and diabetes mellitus. Interview on 11/12/24 at 10:45 a.m., with R5 identified that about 5 months ago he had some gel pens go missing. He reported it to the social service director (SDD) but reports nothing was done. He also reports he is missing the key to his locked drawer and a stylist that was kept on the same string that his key was on. Observation and interview on 11/18/24, at 12:45 p.m., with R5 in the hallway near the dining room, where the SSD director was walking down the hall, R5 stopped her and stated I told you about the gel pen's, can you tell her . R5 pointed to the surveyor. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure 1 of 1 resident (R18) was provided communication with the county care coordinator (CC) and those communications were not discouraged or obstructed, when multiple attempts were made to contact R18 without success.

Inspectors wroteBased on interview and document review, the facility failed to ensure the completed Minimum Data Set (MDS) was accurately coded for 1 of 1 resident (R26) reviewed for wounds.

Inspectors wroteBased on interview and document review, the facility failed to revise the care plan for 2 of 2 residents (R33 and R40). R33 to include daily weights and R40 to include target behaviors for monitoring.

Inspectors wroteBased on interview and document review the facility failed to comprehensively assess and identify target behaviors and non-pharmacological interventions for scheduled antidepressant and antipsychotic medication for 3 of 5 residents (R8, R42 and R246)) reviewed for unnecessary medication usage.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure 2 of 2 opened vials of Tuberculin (TB) purified protein derivative (PPD) solution (used to detect tuberculosis)( (TB)) were appropriately labeled according to manufacturer's guidelines with an open date.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide schedule routine dental services upon request for 1 of 1 resident (R5).

Inspectors wroteBased on observation, interview and document review the facility failed to provide physician ordered physical therapy (PT) services for 2 of 2 residents (R20 and R37).

Inspectors wroteBased on interview and document review, the facility failed to ensure 1 of 1 director of nursing (DON)/infection preventionist (IP) had appropriate training and oversight of the infection control program to management by performing surveillance activities, maintain documentation of incidents, findings, and any corrective actions required.

Inspectors wroteBased on interview and document review the facility failed to ensure residents were free and protected from physical abuse for 2 of 3 residents (R2 and R3) reviewed for resident-to-resident abuse when on two separate occasions R1 physically abused R2 and R3. Additionally failed to implement protection measures according to R1's care plan to prevent re-current physical abuse. Findings Include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had moderate cognitive impairment, did not have sign/symptoms of delirium, and did not have behaviors. The MDS further indicated R1 was independent with walking, toileting, transferring, and personal cares with no upper or lower body impairments. [...]

Inspectors wroteBased on observation, interview, and document review the facility failed to implement and provide adequate supervision and safety interventions for 1 of 3 residents (R1) reviewed for smoking.

Inspectors wroteBased on interview and document review the facility failed to report an allegation of abuse to the State Agency (SA) for 1 of 1 resident (R1) reviewed for allegations of neglect.

Inspectors wroteBased on interview and document review the facility failed to have evidence of analysis and evaluation of the identified Performance Improvement Project (PIP) concerns for 1 of 1 Quality Assurance Performance Improvement (QAPI) program.

Inspectors wroteBased on observation and interview, the facility failed to ensure all 8 licensed nursing staff were appropriately trained and deemed competent to administer insulin.

Inspectors wroteBased on interview and document review, the facility failed to provide mandatory training on 1 of 1 facility's specific Quality Assurance Performance Improvement (QAPI) Program to all staff to include goals and various elements of the program, how the facility intends to implement the program, staff's role in the facility's QAPI program, or how staff was to communicate concerns, problems, or opportunities for improvement to the facility's QAPI program.

Inspectors wroteBased on interview and document review the facility failed to ensure 4 of 9 staff (director of nursing (DON), licensed practical nurse (LPN)-A, nursing assistant (NA)-A, and NA-C) received initial and annual training on Alzheimer's disease or related disorders, assistance with activities of daily living (ADL), problem solving with challenging behaviors, and communication skills.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure 1 of 24 residents (R3) appropriately disposed of cigarette butts after use. This had the potential to affect 23 other residents who also smoked.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure 1 of 3 (R8) residents oxygen (O2) had been administered per physician orders.

Inspectors wroteBased on observation and interview, the facility failed to ensure an insulin pen was appropriately primed prior to administration for 1 of 1 resident (R7).

Inspectors wroteBased on observation, interview and document review, the facility failed to provide a room change notice including the reason for the room change for 3 of 3 residents (R10, R11, R12) reviewed for room change.

Inspectors wroteBased on interview and document review the facility failed to provide notification to the resident and/or resident representative of the facility's bed hold policy at the time of emergency transfer and hospitalization for 1 of 1 (R2) residents reviewed for hospitalization.

Inspectors wroteBased on interview and document review the facility failed to ensure a comprehensive discharge summary that included all four components (recapitulation of stay, final summary of resident's status, medication reconciliation, and post-discharge plan) as required for 2 of 2 residents (R2, R9) who were discharged to the community.

Inspectors wroteBased on observation, interview, and document review the facility failed to complete comprehensive analysis/assessment for potential causal factors/root cause to identify and implement individualized interventions and failed to revise the care plan with identified interventions to prevent and/or mitigate the risk of falls or falls with serious injury for 1 of 3 residents (R7) reviewed for falls.