Wilson Health Care Center

Inspectors wroteBased on record review, staff interview, and facility policy review, it was determined that the facility failed to ensure that a resident's right to formulate an advance directive and to have a properly identified and authorized representative make healthcare decisions was maintained for 1 (Resident #15) of 4 residents reviewed for advanced directives during the annual survey.

Inspectors wroteBased on record review, facility investigative materials, and staff interview, the facility failed to ensure the confidentiality and protection of a resident's medical record from unauthorized disclosure. This deficient practice was identified for 1 of 2 residents (Resident #138) reviewed as part of facility-reported incident investigations during the recertification/complaint survey. The facility implemented corrective actions prior to the start of the survey. Surveyor verification of the facility's corrective measures determined that the deficient practice had been corrected. Therefore, this deficiency is cited as past noncompliance with a compliance date of 07/03/2025.

Inspectors wroteBased on resident interview, record review, and staff interview, the facility failed to ensure that a resident received necessary services and equipment to maintain or enhance independence in activities of daily living, specifically related to bed mobility. This deficient practice was identified for 1 (Resident #65) of 2 residents reviewed for accommodation of needs.

Inspectors wroteBased on interviews and record reviews, it was determined that the facility failed to provide dependent residents with showers. This was evident for 1 (Resident #18) out of 11 reviewed for activities of daily living during the recertification survey.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to ensure that residents had call bells within reach. This was evident for 2 residents (Resident #122 and #181) out of 10 randomly selected residents observed on the unit during the recertification survey.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to maintain the accuracy of the content of R14's EMR (electronic medical record). This was evident for three residents (R14, R179, and R180) as R14's EMR contained medical documents for R179 and R180.

Inspectors wroteBased on medical record review and interviews with facility staff, it was determined the facility failed to ensure that: 1) staff accurately documented if a resident exhibited side effects while receiving anti anxiety medications; 2) staff accurately documented a resident's Treatment Administration Record; 3) staff accurately documented side effects of antipsychotic and anticoagulant medications; 4) antipsychotic medication monitoring on the treatment administration record (TAR) was documented to reflect resident status; 5) resident medical records accurately reflect a resident's status; and 6) resident's medical records were complete and accurately reflects the residents advance directive status. [...]

Inspectors wroteBased on record reviews and interviews, it was determined that facility staff failed to ensure that a resident's Advance Directive (AD) was completed. This deficient practice was evident for 1 (#121) of 3 residents reviewed for AD during the survey.

Inspectors wroteBased on record review and interview with staff, it was determined that the facility failed to ensure a resident was free from misappropriation of resident property. This was evident for 1 facility reported incident (MD00214164) out of 5 facility reported incidents reviewed during the survey.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to include the resident comprehensive care plan goals with the required documentation during a transfer. This was evident for 1 (Resident #55) of 3 residents reviewed for hospitalization.

Inspectors wroteBased on record review and staff interviews, it was determined that facility staff failed to ensure that the resident and resident representative were notified in writing of a transfer and reason for transfer to the hospital. This was evident for 2 (Residents #55 and #54) of 3 residents reviewed for hospitalization.

Inspectors wroteBased on record reviews and interviews, it was determined that facility staff failed to update a resident's care plan to address falls involving equipment. This deficient practice was evident for 1 (#121) of resident review for care plan revision during the survey.

Inspectors wroteBased on interviews, observations, and record reviews, it was determined that facility staff failed to ensure that a resident's wheelchair was safe for use. This deficient practice was evident for 1 (#121) resident review safety hazards during the survey.

Inspectors wroteBased on observations and interviews with the facility staff, it was determined that the facility staff failed to ensure that a resident's call bell was within reach. This was evident for 1 resident (Resident #1) out of 4 residents observed during the survey.

Inspectors wroteBased on record review and interview, it was determined the facility failed to develop and implement abuse prevention policies to ensure the safety of their residents. This was evident for 1 of 1 facility abuse prevention policies and procedures reviewed.

Inspectors wroteBased on record review and interview, it was determined that facility staff failed to recognize and report an injury of unknown within the required time frame. This was evident for 1 (#23) of 1 resident reviewed for injury of unknown origin.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure that an allegation of abuse was thoroughly investigated. This was evident for 1 (#8) of 21 residents reviewed for abuse.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to administer a physician ordered medication for 1 (Resident #22) of 3 residents reviewed for medication administration. Specifically, the facility failed to administer a Rocephin (an antibiotic medication) injection to Resident #22 on 02/28/2024.

Inspectors wroteBased on observation, record review, and interview, it was determined that the facility failed to ensure that all staff were wearing mask during a COVID 19 outbreak. This was evident on 1 of 4 floors in the facility.

Inspectors wroteBased on review of the clinical record and interviews with residents and facility staff, it was determined that the facility failed to ensure residents and /or representatives participated in care plan meetings and to review and revise care plans as necessary. This was evident for 5of 39 residents (Residents #35, #24, #31, #18, and #118) selected for this survey.

Inspectors wroteBased on surveyor observations, resident and staff interviews, and clinical record reviews, it was determined that the facility staff failed to treat residents with respect and dignity. This finding was evident for 1 of 2 residents reviewed for the dignity care area during the survey (Resident #287).

Inspectors wroteBased on surveyor observation, resident and facility staff interview, it was determined that the facility staff failed to keep residents' call lights within reach to allow residents to call for staff assistance. This finding was evident for 2 of 36 residents on the 4 North unit (Residents #77 and #103).

Inspectors wroteBased on surveyor observation, clinical record review and staff interview, it was determined that the facility staff failed to develop and implement a baseline care plan for 1 of 39 residents reviewed during the survey (Resident #284).

Inspectors wroteBased on surveyor review of the clinical records and facility staff interview, it was determined that the facility staff failed to develop a comprehensive resident centered care plan for 1 of 39 residents selected for review during the survey (Resident #77).

Inspectors wroteBased on surveyor observation, review of the clinical record, and staff interviews, it was determined that the facility staff failed to weigh 1 of 6 residents reviewed for the nutrition care area (Resident #285).

Inspectors wroteBased on record review and surveyor interview, it was determined that the facility staff failed to adequately monitor residents receiving antipsychotic medications for side effects, and failed to attempt a gradual dose reduction of psychotropic medication. This finding was evident for 2 of 5 residents reviewed for unnecessary drugs (Residents #9 and #118).

Inspectors wroteBased on surveyor observation and staff interviews, it was determined that the facility staff failed to serve food under sanitary conditions. This finding was evident in the facility's dining room on the second floor north dining room, and on the fourth-floor during the lunch observation.

Inspectors wroteBased on surveyor observations, clinical record review and staff interview, it was determined that the facility staff failed to follow standard and transmission-based precautions to prevent spread of infection while providing care. This finding was evident for 1 of 7 units in the facility.