Wilber Care Center

Inspectors wroteLicensure Reference Number 175 NA 12-006.09(I)Based on record review and interviews, the facility failed to implement interventions to provide a safe environment when residents are identified as at risk for elopement (when an individual with dementia leaves a safe or supervised area without authorization or knowledge) for Resident 1, Resident 2, and Resident 3. This affected 3 of 3 residents sampled for elopement. The facility census was 33.

Inspectors wroteLicensure Reference 175 NAC 12-006.02(H)Based on record reviews and interviews, the facility failed to submit an investigative report for Resident 1 within the required time frame. This affected 1 of 1 residents sample for reporting. The facility census was 33.

Inspectors wroteLicensure Reference Number NAC 12-006.18(B) Based on observation, record review and interview, the facility failed to wear the required Personal Protective Equipment (PPE-personal protective equipment-special equipment, including gloves, gown, masks and eye protection, worn to prevent exposure to hazards such as infectious materials), place soiled linen in a linen bag, ensure supplies were placed on a clean surface and throw a soiled glove in the trash can all during wound care for Resident 1, and failed to perform peri-care in a manner to prevent cross-contamination, and complete hand hygiene when changing gloves and after assisting with cares for Residents 11 and 12. This affected 3 out of 3 sampled residents. The facility census was 30.

Inspectors wroteLicense reference number NAC 12-007.03(K)Based on observation, and interview, the facility failed to provide a safe walkway in the hallway for ambulatory residents. This affected 1 out of 2 sampled residents but had the potential to affect all ambulatory residents. The facility census was 30.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.02(H) Based on record reviews and interviews, the facility failed to report suspicions of abuse to the state agency within the required timeframe. This affected 2 residents, (Resident 1 and Resident 3). The facility census was 32.

Inspectors wroteBased on record reviews and interviews, the facility failed to complete annual performance evaluations for 4 of 5 Nurse Aides sampled. This had the potential to affect all residents in the facility. The facility census was 37.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(B)(ii)(1) Based on record reviews and interviews, the facility failed to provide the required annual in-service training for 3 of 5 Nurse Aides sampled. This had the potential to affect all residents in the facility. The facility census was 37.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.(18)(D) Based on observations, record reviews and interviews, the facility failed to ensure hand hygiene (using an alcohol-based hand rub (ABHR) or washing hands with soap and water) was completed in a manner to prevent cross-contamination during peri-care (washing the genitals and anal area) for Resident 8 and Resident 25 and during wound care for Resident 12. This affected 3 of 4 residents observed for peri-care and wound care. The facility census was 37. A record review of the facility's Handwashing/Hand Hygiene policy dated 12/05/2023 revealed that hand hygiene should be completed in the following situations: Before and after direct contact with residents; Before handling clean or soiled dressings; Before moving from a contaminated body site to a clean body site during resident care; After contact with blood or body fluids; [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(B) Based on record reviews and interview, the facility failed to ensure the accuracy of the Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) regarding use of an anti-anxiety medication for Resident 8 and for use of a Bilevel Positive Airway (BiPAP-a machine used to deliver positive airway to a person's airway to prevent it from closing during sleep) for Resident 18. This affected 2 (Resident 8 and Resident 18) of 16 residents sampled for MDS accuracy. The facility census was 37.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 Based on interview and record review, the facility failed to complete a trauma based assessment for 1 (Resident 7) of 5 sampled residents. The facility census was 37.

Inspectors wroteLicensure Reference number 175 NAC 12-006.09 Based on record review and interviews, the facility failed to notify a resident representative and provider regarding a change in condition for 1 (Resident 37) of 1 sampled residents. The facility census was 35.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D7b Based interview, and record review; the facility failed to conduct a thorough investigation to determine the root-cause of falls and failed to develop and implement effective interventions to minimize and/or prevent falls for 1 (Resident 23) of 1 sampled resident. The facility census was 35.

Inspectors wrote175 NAC 12-006.05(5) Based on record review and interviews, the facility failed to provide a written notice of transfer to Resident 23 and Resident 6 and/or their representatives upon transfer to the emergency room (ER). The facility failed to notify the Ombudsman (a state official who works with nursing home and assisted living residents who helps answer resident concerns and complaints and advocates for resident rights and their well-being) of transfer for Resident 23 and Resident 6. This affected 2 of 2 residents sampled for hospitalization. The facility census was 33.

Inspectors wroteB. An observation on 04/05/23 at 9:00 AM revealed Resident 6's CPAP mask was laying on top of CPAP machine without being covered. An observation on 04/06/23 at 11:25 AM Resident 6's CPAP mask was laying on top of CPAP machine without being covered. Record review of CPAP/BIPAP Cleaning Policy dated 3/7/11 did not mention how to store a CPAP mask to prevent contamination. Interview with the Infection Preventionist (IP) on 4/6/23 at 1:40 PM revealed that the resident's CPAP mask was not being stored in a manner to prevent contamination. Interview with the Director of Nursing (DON) on 04/06/23 at 2:00 PM revealed that the resident's CPAP mask was not being stored in an manner to prevent contaminiation. Based on observation, record review, and interview; [...]