Wilson's Creek Nursing & Rehab

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen ceiling, walls, floors, appliances, and dishware were clean and in good repair, failed to handle left-overs appropriately, and failed to date foods after opening. This deficient practice had the potential to affect 128 of 128 residents who received meals prepared in the facility's only kitchen. The facility census was 128. Review of the facility policy titled, Basics for Handling Food Safely, dated 08/13, showed the following: -Leftovers- Place food into shallow containers and immediately put in the refrigerator or freezer for rapid cooling; -Hot food should be held at 140 F or warmer; -Cold food should be held at 40 degrees F or colder. Review of the facility guidelines itemized in the Nutrition and Dining Services Manual, dated May 2015, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure monthly medication regimen reviews (MRR) were completed in a timely manner for five of five sampled residents (Residents #104, #33, #34, #90, and #89) reviewed for unnecessary medications. The facility census was 128. 1. Review of Resident #104's Resident Face Sheet, undated, found in the electronic medical record (EMR) under the Continuity of Care (CCD) Tab, showed the following: -admission date of 05/12/23; -Diagnoses included major depression, anxiety, and post-traumatic stress disorder (PTSD- mental health condition that's triggered by a terrifying event - either experiencing it or witnessing it. Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event). [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor for side effects and target behaviors for three residents (Resident #33, #34, and #104) of five sampled residents reviewed for unnecessary medications and who received psychotropic medications. The facility census was 128. 1. Review of Resident #104 Resident Face Sheet, undated, found in the electronic medical record (EMR) under the Continuity of Care (CCD) Tab, showed the following: -admission date of 05/12/23; -Diagnoses included major depression, anxiety, and post-traumatic stress disorder (PTSD - makes one feel stressed and afraid after the danger is over). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), with an Assessment Reference Date (ARD) of 08/17/23, showed the following: -Cognitively intact; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a bed-hold policy was provided to all residents at time of transfer when staff failed to provide a written bed hold notice at the time of a transfer to two (Resident #108 and #20) of two sampled residents. Facility census was 128. Review of the facility's Bed Hold Policy Guidelines showed the following: -The facility will notify all residents, and/or their representative of the bed hold policy guidelines; -The notification shall be given upon admission of the facility; at the time of transfer to the hospital or leave; and at the time of non-covered therapeutic leave. 1. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure a Level 2 PASARR (Pre-admission Screening and Resident Review) screen was completed for one resident (Resident #45) and failed to incorporate recommendations from a Level 2 PASARR into one resident's (Resident #104) overall plan of care. Six residents were reviewed for PASARR. The facility census was 128. Review of the facility's Preadmission Screening and Annual Resident Review (PASARR) Tool, dated 2017 , showed the following: -Intent was to ensure that the facility coordinates with the appropriate, State-designated authority, to ensure that individuals with a mental disorder, intellectual disability or a related condition receives care and services in the most integrated setting appropriate to meet their needs; -Coordination includes: [...]

Inspectors wroteBased on facility policy, record review, and staff interviews, the facility failed to ensure a Level 1 PASARR (Pre-admission Screening and Resident Review) was complete for one resident (Resident #24) of six residents reviewed for PASARR. The facility census was 128. Review of the facility's Preadmission Screening and Annual Resident Review (PASARR) Tool, dated 2017, showed the following: -Intent is to ensure that the facility coordinates with the appropriate, State-designated authority, to ensure that individuals with a mental disorder, intellectual disability or a related condition receives care and services in the most integrated setting appropriate to meet their needs; -The PASARR process requires that all applicants to Medicaid-certified nursing facilities be screened for possible serious mental disorders or intellectual disabilities and related conditions; [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure staff safely turned and repositioned a resident during care, failed to complete fall investigations, and failed to conduct root cause analysis of falls in an effort to identify appropriate intervention to help prevent future falls for one resident (Resident #69) of four sampled residents reviewed for falls. The facility census was 128. Review of the facility's fall prevention manual, dated June 2006, showed the following: -Keep a fall log to analysis causes of falls and facility trends or needs. The data in the log may point to variables that are present when falls commonly occur' -Review the surveillance fall log to make sure the process is working, and falls are being prevented; -The committee should plan interventions individualized for each resident; [...]

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to ensure a medication error rate of less than 5% when staff made three errors out of 30 opportunities, resulting in a 10.00% error rate. The errors involved two residents of five residents (Resident #71 and #124) reviewed for medication administration. The facility census was 128. 1. Review of the directions for use for Miralax showed stir and dissolve into any four to eight ounces of beverage (cold, hot or room temperature) then drink. Review of Resident #71's Resident Face Sheet, undated, found in the electronic medical record (EMR) under the Continuity of Care (CCD) Tab, showed the following; -admission date of 04/10/18; -Diagnoses included constipation. Review of the resident's Physician Order Report, dated 10/30/23 to 11/30/23, found in the EMR under the Orders tab, showed the following: [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure all residents were free from abuse when one staff member (Certified Nurse Aide (CNA) Q) used curse words when speaking to one resident (Resident #107). The facility census was 133. Record review of facility's policy titled Abuse, Neglect, Exploitation, and Misappropriation, undated, showed the following: -Every nursing home resident has the right to quality care and quality of life including freedom from neglect, abuse, exploitation, and misappropriation of property; -Abuse is deliberate infliction in injury, unreasonable confinement, intimidation, or punishment which results in physical harm, pain, mental anguish. This also includes verbal, sexual, physical, or mental abuse as well as abuse through technology. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean, comfortable, and homelike environment when there were urine odors on the special care unit (SCU - locked memory unit); floor tiles in one shared resident bathroom were stained and smelled of urine; and a hot water faucet did not work in one resident's room (Resident #85) room. The deficient practice had the potential to affect all residents who lived on the SCU. The facility census was 133. 1. Observations beginning on 7/12/21, beginning at approximately 9:15 A.M., showed upon entering the SCU a strong urine odor around the nurses' station and on the resident hallways. Observation on 7/12/21, at approximately 10:00 A.M., of resident room C119 (SCU) showed the resident's sheets had been stripped from his/her bed. On the floor next to the bed was a puddle of yellow substance that looked like urine. [...]

Inspectors wroteBased on observation and interview, the facility failed to store and prepare food in accorandance with professional standards of practice and protect from possible contamination when two dietary staff (Dietary Staff (DS) K and DS L) failed to wear beard nets when working in the kitchen; failed to ensure trash cans were properly covered when not actively in use; and when dietary staff placed left over food from breakfast in the walk-in uncovered to allow the food to cool. The facility census was 133. 1. Record review of the Missouri Food Code, dated 6/3/13, showed the following: -Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain an infection control program that provided a safe and sanitary environment for all residents during a Coronavirus Disease 2019 (COVID-19, an infectious disease caused by severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2)) pandemic when staff failed to follow their policy and standards of practice and failed to wear personal protective equipment (PPE) facemasks appropriately around at least 12 residents (Resident #8, Resident #33, Resident #45, Resident #51, Resident #58, Resident #62, Resident #70, Resident #85, Resident #97, Resident #103, Resident #104, and Resident #106). The facility census was 133. Record review of the facility's policy titled Outbreak Management, dated 3/17/21, showed the following: [...]

Inspectors wroteBased on observation and interview, the dietary staff (DS) failed to clean the metal wire shelves used in the kitchen to store food on and failed to ensure the two intake vents above the walk-in freezer and walk-in cooler were cleaned. The facility census was 133. 1. Observation on 7/12/21, beginning at 8:49 A.M., showed the following metal wire shelves were dirty with a build-up of fuzzy lent: -The metal wire shelves across from the steam table where plates were stored; -The metal wire shelves near the dish room where cups and silverware were stored; -The metal wire shelves to the right of the three vat sink. Observation on 7/14/21, beginning at 8:06 A.M., showed the following metal wire shelves were dirty with a build-up of fuzzy lent: -The metal wire shelves across from the steam table where plates were stored; [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to consistently provide nutritional interventions, including supplements and cueing, for one resident (Resident #12) with a history of weight loss The facility was census of 133. Record review of the facility's policy titled Nutritional Risk Interventions, dated April 2011, showed the following: -The individual condition of each resident at nutritional risk must be considered when instituting nutritional interventions; -Unacceptable parameters of nourishment include weight loss; -Risk factors for malnutrition includes poor eyesight. 1. Record review of Resident #12's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission dated 09/03/19; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff administered medications with an error rate of less than 5% when staff failed to correctly administer fast-acting insulin (a manufactured drug that helps to regulate the amount of sugar in the blood) for two residents (Resident # 49 and Resident # 91), out of 25 opportunities, resulting in an medication error rate of 8%. The facility census was 133. Record review of the facility's Diabetes Mellitus (an impairment in the way the body regulates and uses sugar as a fuel) Control Policy, dated 3/2015, showed the policy did not address time frames between fast acting insulin administration and eating times. Record review of the facility's Medication Administration Policy, dated 3/2015, showed the policy did not address time frames between fast acting insulin administration and eating times. [...]