Wilkinson Residential Health Care Facility

Inspectors wroteBased on observation, record review, and interview conducted during a recertification survey, the facility did not ensure control and accountability, determine that drug records were in order, that an account of all controlled drugs was maintained and periodically reconciled. Specifically, (a.) a count was not completed prior to narcotic access keys being handed from one licensed nurse to another; (b.) nursing staff did not document nursing unit narcotics as having been counted by two licensed nurses and signed at the beginning and end of each shift on the facility-provided Controlled Substance Count Sheets for three (3) of three (3) nursing units; and (c.) the facility did not complete periodic reconciliation of controlled substance records. This is evidenced by: The facility Policy and Procedure titled Controlled Substance Shift Count, last reviewed 7/2023, documented: [...]

Inspectors wroteBased on record review, observation, and interview conducted during a recertification and abbreviated (Case #NY00377111) survey , the facility did not ensure that resident environments were as free from accidents or hazards as was possible for three (3) (Resident #s 40, 44, and 358) of five (5) residents reviewed for accidents and hazards. Specifically, (a.) Resident #40, who was at risk for elopement and required supervision, was left alone outside unsupervised for 98 minutes on [DATE], and unable to get back into the building; (b.) an expired ointment medication was left on the Resident #44 ' s bedside table on [DATE], permitting access to the ointment by the resident or anyone that entered the room; [...]

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure that each resident received the necessary respiratory care and services that followed professional standards of practice, the resident's care plan, and the resident's choice for three (3) (Resident #'s 44, 63, and 79) of five (5) residents reviewed for oxygen administration. Specifically, (a.) supplemental oxygen flow rate was not ordered by the physician for Resident #'s 44 and 63; (b.) for Resident #79 oxygen therapy was not monitored and physician orders were not followed for cleaning and maintaining respiratory therapy equipment according to professional standards of practice. This is evidenced by: A review of the facility policy titled Oxygen Administration and Use, last reviewed 8/2024, documented that oxygen use for residents was per physician orders. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification and abbreviated (Case # NY00358788) survey, the facility did not ensure it had sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. Specifically, (a.) the facility did not perform the appropriate competency evaluations for licensed nursing staff to measure the pattern of knowledge, skills, abilities, behaviors and other characteristics that an individual needs to perform work roles or occupational functions successfully; [...]

Inspectors wroteBased on interview and record review conducted during the recertification survey, the facility did not use the services of a Registered Nurse for at least eight (8) consecutive hours a day, seven (7) days a week. Specifically, a review of staffing revealed a Registered Nurse was not scheduled for eight (8) consecutive hours per day on 1/19/2025 and 3/02/2025. This is evidenced by: The facility assessment dated 2024, documented that the staffing plan was based on the resident population and their needs for care and support. The staffing plan documented the following daily staffing needs: one (1) to three (3) Registered Nurses on day shift, zero (0) to two (2) Registered Nurses on evening shift, and zero (0) to one (1) Registered Nurses on night shift. [...]

Inspectors wroteBased on observation and staff interview conducted during the recertification survey, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen. Specifically, food was not cooled properly, dented cans were with the common stock, and sanitizing solution testing papers were expired. This is evidenced by: During observations in the main kitchen on 5/19/2025 at 9:40 AM: • Cooked pasta in the walk-in refrigerator was 47 degrees Fahrenheit. • One #10 can of Banana Pudding had a V-shaped dent in the seam which broke the seal of the can (can was in the walk-in refrigerator speed rack). Director of Food and Nutrition disposed of the pasta and the #10 can of Banana Pudding immediately. [...]

Inspectors wroteBased on record review and interviews conducted during the recertification and abbreviated survey (Case #s NY00343349, NY00344172, NY00345225, and NY00379263), the facility did not ensure the resident's right to be free from abuse and neglect for three (3) (Resident #s 40, 44, and 53) of eight (8) residents reviewed for abuse and neglect. Specifically, (a.) on 6/02/2024, Resident #40 was left unattended outside of the facility by Certified Nurse Aide #7 for an extended period of time; (b.) on 6/12/2024, Certified Nurse Aide #8 did not follow Resident #44's care plan to use a mechanical lift which resulted in an injury to the residents foot; (c) on 5/27/2025, Certified Nurse Aides #'s 5 and 6 did not provide personal care to Resident #53 the way the resident preferred, causing Resident #53 to fight against the care, sustaining a bruise to their hand. This is evidenced by: [...]

Inspectors wroteBased on record review and interview conducted during a recertification and abbreviated survey (Case #NY00358788), the facility did not ensure that all allegations of abuse were thoroughly investigated for one (1) (Resident #359) of eight (8) residents reviewed for abuse. Specifically, Resident #359 reported an allegation of verbal/metal abuse and rough treatment during care given on the evening shift of 10/25/2024 by five (5) facility staff during an insertion of an indwelling Foley Catheter. The facility initiated an investigation on 10/28/2024, and did not determine where a bruise of unknown origin occurred and did not investigate the source of the bruise until 10/30/2024. This is evidenced by: Cross reference with F-684. [...]

Inspectors wroteBased on record review and interview conducted during the recertification and abbreviated survey (Case #NY00358788), the facility did not ensure residents received appropriate care and treatment in accordance with professional standards of practice to maintain or improve their physical, mental, and psychosocial well-being for 1 (one) (Resident #359) of 1 (one) resident reviewed. Specifically, for Resident #359, Licensed Practical Nurse #2 did not notify the facility health care practitioner after the resident had a mental status change and became resistant to care during a physician ordered health care procedure on 10/25/2024. Furthermore, a Registered Nurse did not document or assess Resident #359 when a procedure was ordered and mental status change occurred. [...]

Inspectors wroteBased on observation, record review, and interviews during a recertification survey dated 08/03/2022 through 08/09/2022, the facility did not ensure comprehensive care plans (CCP) were developed and implemented for each resident consistent with the resident rights and that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs for 5 (Resident #'s 9, 43, 71, 74, and #83) of 24 residents reviewed. [...]

Inspectors wroteBased on record review and interviews during a recertification survey from 8/3/2022 - 8/9/2022, the facility did not ensure that a resident who required dialysis received such services, consistent with professional standards of practice, for 1 (Resident #74) of 1 resident reviewed for dialysis. Specifically, for Resident #74, the facility did not ensure that there was ongoing communication from the facility to the dialysis center regarding dialysis care and services and nursing home staff did not provide immediate monitoring and documentation of the status of the resident's access site upon return from dialysis treatment. This is evidenced by: Resident #74 Resident #74 was admitted with diagnoses of chronic kidney disease, end stage renal disease, and anemia. [...]

Inspectors wroteBased on record review and interview during the recertification survey dated 8/3/2022 through 8/9/2022, the facility did not ensure it developed a policy and procedure for the medication regimen review (MRR) that included timeframes for the different steps in the process. Specifically, the facility's Drug Regimen Review policy did not include timeframes for the physician and/or facility staff to complete the review of reported irregularities requiring immediate or urgent action that were identified by the consultant pharmacist. This is evidenced by: The Policy and Procedure (P&P) titled Consultant Pharmacist Drug Regimen Review dated 2/18, documented when the consultant pharmacist identified an irregularity that required immediate or urgent action, the pharmacist would notify the physician and/or the Director of Nursing (DON) or designee at the time the irregularity was identified. [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey dated 08/03/22 through 08/09/22, the facility did not ensure food was stored, prepared, distributed, or served food in accordance with professional standards for food service safety in the main kitchen. Food preparation equipment and serving areas are to be kept clean and in good repair, and a test kit is to be available to measure the parts per million (ppm) concentration of the solution used to sanitize equipment. Specifically, four (4) rubber spatulas for cooking had splits and cracks on the edges and were not cleanable; the can opener holders, stove, fire extinguishers, floor under cooking equipment, and floor in corners and next to walls were soiled with food particles or a black build-up; [...]

Inspectors wroteBased on record review and interviews during a recertification survey, the facility did not ensure within 14 days after the facility completed resident assessments that the assessments were electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the Center for Medicare and Medicaid Services (CMS) System for 2 (Resident #'s 1 and 2) of 2 residents reviewed for resident assessment. Specifically, the facility did not ensure the required quarterly Minimum Data Sets (MDS's) were completed and transmitted as required to CMS. This is evidenced by: Resident #1 The resident's quarterly MDS dated [DATE], documented the assessment was not completed until 12/26/19. The facility did not provide documentation of the MDS transmission date. [...]

Inspectors wroteBased on observations, record review, and interviews during a recertification survey the facility did not ensure that it provided, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, for one (Resident #40) of one resident reviewed for activities. Specifically, the facility did not ensure that activities were provided to the resident based on his/her abilities and preferences. This is evidenced by: Resident #40: The resident was admitted with the diagnoses of Alzheimer's dementia, chronic kidney disease, and HTN. [...]

Inspectors wroteBased on observations, record review, and interviews during a recertification survey the facility did not ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for one (Resident #40) of three residents reviewed for pressure ulcers. Specifically, for Resident #40, the facility did not ensure that when bleeding was noted to an area of a previous pressure Ulcer (PU), that the the area was assessed, the MD notified, the care plan updated, and a new treatment started. This is evidenced by: [...]

Inspectors wroteBased on observations, record reviews, and interviews during a recertification survey the facility did not ensure each resident who used psychotropic drugs received gradual dose reductions (GDRs) unless clinically contraindicated, in an effort to discontinue the drugs and the documentation did not include adequate indications for the use of psychotropic medications for 3 (Residents (#'s 2, 81, and 91) of 5 residents reviewed for psychotropic medications. Specifically, for Resident #2, the facility did not attempt a gradual dose reduction (GDR) for Xanax (an anti-anxiety medication) twice within the first year after initiation of the psychotropic medication; for Resident #81, the facility did not ensure that the resident's behaviors were monitored and documented to justify an increase in Seroquel (an anti-psychotic medication); [...]

Inspectors wroteBased on observation and interviews during the recertification survey, the facility did not ensure residents received drinks consistent with their preferences on 1 of 3 units. Specifically, the facility did not ensure resident's received coffee. This is evidenced by: The Policy and Procedure (P&P) titled Hydration dated 6/16, documented residents were to receive coffee at breakfast, lunch, and dinner. The P&P documented bevereage preferences would be obtained from the resident and/or family and the daily pattern would be adjusted based on preferences. During an lunch dining room observation on 1/28/20 at 12:01 PM, a resident asked when they would be getting some coffee. During an interview on 1/29/20 at 8:41 AM, Resident #70 stated he/she did not get coffee this morning, and did not ask for it because it was on her ticket. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety. Foods time/temperature controlled for safety (TCS foods) are to be cooled to 41 degrees Fahrenheit (F) within 6 hours provided the food is cooled from 135F to 70F within the first two hours of cooling. Food contact surfaces and floors must be kept clean. Specifically, TCS foods were not cooled safety, food contact surfaces were not clean, and there was a build-up of grease on the floor in the main kitchen. This is evidenced as follows. The main kitchen was inspected on 01/28/2020 at 09:00 AM. The temperature of the pasta salad in the produce walk-in cooler which was prepared on 01/27/2020 was 46 degrees Fahrenheit (F). [...]

Inspectors wroteBased on record review and interview during the recertification survey, the facility did not ensure a policy was developed regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. Specifically, the facility did not ensure the policy included a process for assisting residents in accessing and consuming the food if a resident was unable to do so on his or her own. This is evidenced by: A Policy and Procedure (P&P) titled Food Safety Requirements and Use and Storage of Food and Beverage Brought in for Residents dated 4/2018, did not include documentation of a process for assisting residents in accessing and consuming the food if a resident was unable to do so on his or her own. [...]