Wolf Creek Care Center

Inspectors wroteBased on interview and record review, the facility failed to obtain consent for the administration of a Covid Vaccine (vaccine designed to induce immunity against SARS-Co-V-2, virus responsible for coronavirus disease 2019) for one of two sampled residents (Resident 1) when Resident 1 was administered the vaccine after Resident 1's RP's (Responsible Party) declined the vaccine. This failure resulted in Resident 1 to receive a covid vaccine without consent and violated the resident's RP's right to make health care decisions.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident safety for two out of six sampled residents (Resident 1 and Resident 2) when:1. Resident 1 left the facility without staff knowledge and was found at a gas station without her Wander Guard (wearable monitoring device that alerts caregivers when a resident leaves a protected area); and2. Resident 2 had an avoidable fall (unintentional fall that happens because of identifiable and correctable factors) when she was not properly secured during transportation to an appointment. This failure resulted in Resident 1 leaving the facility unsupervised and increased her risk for harm and injury and in Resident 2 sustaining a left femur (lower end of thigh bone) fracture (crack, break, or chip in bone) that required surgery.

Inspectors wroteBased on interview and record review, the facility failed to follow their Policy and Procedures (P&P) and ensure professional standards of practice were met for one of six sampled residents (Resident 3) when, Resident 3 was administered medications with possible drug interactions without clarification from the doctor. This failure had the potential to have caused adverse outcomes and worsen Resident 3's condition and decreased the potential to provide safe administration of medication. [...]

Inspectors wroteBased on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for a census of 53 residents when the Registered Dietician (RD) and Dietetic Services Supervisor (DSS) were both hired as part time (an employee who is scheduled to work and who does work a schedule of anything under 32 hours per week) employees. This failure had the potential for unsafe food handling and spread of food borne illnesses in a highly susceptible population.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food storage and preparation, and maintenance of food contact surfaces were in accordance with professional standards for food safety for the 53 residents who ate facility prepared meals when: 1. Three out of three small cutting boards had stains, and two out of six large cutting boards had deep scratches; and, 2. A box of garlic bread, a box of fried eggs, and a box of bacon were found with ice crystals built-up, opened and were exposed to air in the freezer. These failures had the potential to put residents at risk for foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for one out of 16 sampled residents (Resident 17) when: 1. Resident 17's nebulizer (machine that turns liquid medicine into a mist that can be easily inhaled) face mask was not changed every seven days and was left uncovered when not in use; and, 2. Resident 17's oxygen nasal cannula (a medical device with two prongs that is connected to an oxygen source used to deliver supplemental oxygen directly into the nostrils) was not changed every seven days. These failures resulted in an increased risk for cross-contamination (movement or transfer of harmful bacteria from one person, object, or place to another), potential exposure to germs, and may cause infection to Resident 17.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician orders were followed in accordance with the facility's policy and procedures as well as professional standards of care for one out of 16 sampled residents (Resident 20), when Resident 20 did not receive insulin (hormone that controls the amount of sugar in the blood) medication within the parameters as ordered by the physician. This failure had the potential for Resident 20 to experience hypoglycemia (condition where the level of sugar in the blood drops below a healthy range) and for the resident to not achieve their highest practicable well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of 16 sampled residents (Resident 2) received treatment and care in accordance with professional standards of practice, and facility's policy, procedure (P&P), and care plan when Resident 2's suprapubic catheter (a tube that drains urine from the bladder through a small incision in the lower abdomen) drainage bag was not positioned below Resident 2's bladder during a wound care treatment. This failure had the potential for Resident 2 to develop infection and possible suprapubic catheter complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of 16 sampled residents (Resident 43) received appropriate pain management services consistent with professional standards of practice, facility's policy and procedure (P&P), and physician's order when Resident 43's pain medication orders were not consistently followed. This failure had the potential for Resident 43 to experience over medication, not achieve pain relief, and not attain her highest practicable well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a sanitary environment when one out of three sampled residents, (Resident 1), had oxygen tubing, suctioning tubing and yankhauer (hard tube-like plastic tool which is placed into a person ' s mouth to suction secretions) laying on Resident 1 ' s bedroom floor. This failure had the potential to transmit communicable diseases and infections to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to protect Resident 1 from abuse when Resident 1 was scratched on the face and her hair was pulled by Resident 2. This failure caused a scratch to the left cheek and mild scalp pain for Resident 1, potentially leading to adverse clinical outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive care plan to reflect the care needs for four of 14 Residents (Residents 8, 14, 33, and 45) when: 1. A care plan problem and intervention for Hoyer lift (a mechanical lift used to safely transfer residents) use was not listed for Resident 45. This failure resulted in a dislocated right shoulder and pain. 2. A comprehensive care plan was not developed for antipsychotic (medication use to treat behaviors) use for Resident 33. This had the potential for staff to be unaware of potential adverse events, side effects or therapeutic effect. 3. Resident 8's skin assessment intervention was not implemented. This had the potential to result in skin injury going unnoticed and untreated. 4. Resident 14's weekly weight interventions were not implemented. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. The blue plastic holder for the can opener and the base was unsanitary. 2. The chipped paint on white shelves in both three-door reach in refrigerators were not easily cleanable. 3. The rusting area of the shelf on the table had stored mixing bowls which had the potential to contaminate the clean metal bowls and containers. 4. A visible amount of water was observed in a kitchen drawer. 5. Four of the kitchen drawers had yellowish sticky food particles on the inside of the drawers which stored cooking utensils. 6. The ventilator fans had black debris in both three-door reach in refrigerators. 7. The cooking utensils had dried food particles. 8. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a care plan for one of fourteen sampled residents (Residents 8) was revised and updated to reflect current fall risk interventions. This failure had the potential for resident's individual care needs to go unrecognized, and a risk for a decline in residents physical, mental, and psychological status.

Inspectors wroteBased on interview and record review, the facility failed to transfer one of fourteen sampled residents, (Resident 45) safely using a Hoyer lift (a mechanical lift used to transfer residents safely) per resident's care plan when two Certified Nursing Assistants (CNA)transferred Resident 45 from the bed to the wheelchair without a lift. This failure resulted in an avoidable accident when Resident 45 sustained a dislocated right shoulder that caused pain.

Inspectors wroteBased on observation, interview and record review the facility failed to provide individualized dementia (the loss of cognitive functioning - thinking, remembering, and reasoning) care plan for two of fourteen sampled residents (Resident 28 and Resident 34). This failure resulted in Resident 28 feeling cold and startled and had the potential to adversely affect the psychosocial well-being of all dementia residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe standards of medication administration for three of four sampled residents (Residents 164, 39, 33) when: 1. Resident 164 was instructed to take one puff on an inhaler instead of two puffs, resulting in receiving half of the ordered dose, and, 2. Resident 39's identification was not verified at the time of medication administration which placed him at risk of receiving the wrong medication, and, 3. Resident 33 was given a topical antibiotic ointment and the nurse failed to check the expiration date which placed the resident at risk of receiving expired and/or ineffective medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were stored, labeled and disposed of correctly for two of 14 residents (Residents 19 and 34) when: 1. a. Two tubs of triamcinolone cream (a medicated cream to treat certain skin conditions) were found in the treatment cart when they should have been disposed of as the orders for use had expired, and b. An opened bottle of latanoprost (a medicated solution to treat a condition that leads to vision loss) that had not been dated when it was first opened was found in medication cart 2, and, c. An opened bottle of risperidone (a medication to treat certain mood/mental disorders) was found unlabeled in medication cart 2. These failures had the potential for medication misuse and ineffectiveness.

Inspectors wroteBased observation, interview, and record review, the facility failed to maintain complete documentation of controlled drugs for two of 14 residents (Residents 35 and 22) when a licensed nurse (LN) did not document doses given at the time of administration. This failure resulted in the incorrect accounting of federally controlled drugs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity for two of three residents (Residents 16 and 46) when they were not informed of, nor provided with the opportunity to exercise the right to refuse a room change. This resulted in avoidable psychosocial distress and could have a negative impact on the resident's health and well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and/or implement infection control policies and procedures when: 1. No policy and procedure was found for use of the residential style washing machine in the laundry room (used for small loads). 2. Restorative Nurse Assistant (RNA) touched the lid of a trash can, then proceeded to assist residents with eating without performing hand hygiene. This failure resulted in the potential for cross-contamination of germs and viruses to residents, which could negatively impact their health and well-being.

Inspectors wroteBased interview, and record review, the facility failed to provide written notice, including the reason for the change, before the resident's room or roommate in the facility was changed for three of three residents review for recent room changes (Residents 8, 16, and 46). This failure resulted in a process that did not take into account the Resident's preferences before making room changes for Residents are made.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident right to refuse a room transfer, for one of three residents (Resident 16). This resulted in Resident 16, being moved to a new room without consent, solely for the convenience of the facility.

Inspectors wroteBased on interview and record review the facility failed to prevent physical abuse when Resident 21 was the aggressor in an altercation with Resident 47. This failure resulted in Resident 47 sustaining bruises from being pinched on the arm by Resident 21.

Inspectors wroteBased on observation, interview and record review, the facility failed to store and prepare food in a safe and sanitary manner when a container filled with leftover chicken noodle soup was found unlabelled and areas on the clean side of the kitchen were found to contain areas of grime and food splatter, potentially exposing the residents to food borne illnesses associated with out-dated foods and unclean surfaces.