Wilkinson County Senior Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility policy review, the facility failed to properly store frozen and dry storage food in accordance with professional standards for food service safety for one (1) of four (4) days of survey.Findings Include: A record review of the facility policy Storage of Frozen Foods with a review date of 11/23 revealed, The facility ensures the quality and safety of frozen food through accepted storage practices. 8. Opened boxes with liners should be closed and sealed tightly with packing tape or twist ties .On 08/25/2025 at 10:48 AM, during an initial tour of the kitchen with the Dietary Manager (DM), multiple concerns were identified in the freezer and dry storage areas. In the freezer, several food items were observed open and exposed to air inside their original cardboard boxes, including [NAME] biscuits, sugar-free chocolate chip cookies, Salisbury steak patties, chicken patties, and fish sticks. In the dry storage room, a box of yellow cake mix was found stored in a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and policy review, the facility failed to ensure residents were treated with respect and dignity for three (3) of 27 residents on A Wing. (Resident #1, Resident #2, and Resident #3). Findings Included: A review of the facility's resident document, undated, revealed .As a resident in a long-term care facility, you have many rights guaranteed by law . Your rights include: A dignified and comfortable living environment . Dignity and Respect You have the right to dignity and respect in the care you receive and the setting you live in. Resident #1 A record review of the admission Record revealed the facility admitted Resident #1 on 4/11/25 with diagnoses including Atrial Fibrillation. A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/22/25 for Resident #1 revealed a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment. A record review of the facility's investigation revealed that on 5/12/25, Resident #1 reported to the Social Services Director that a night shift…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff and Resident Representative (RR) interview, record review, and facility policy review, the facility failed to ensure the comprehensive care plan was implemented for Activities of Daily Living (ADL) for one (1) of 16 sampled residents. (Resident #30) Findings include: Review of the facility's policy titled, Care Plan-Comprehensive, dated 10/2016 revealed, Policy Statement: .An individualized (person centered) comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident . 1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or resident representative, develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain . 3. Each resident's comprehensive care plan is designed to . d. Reflect the resident's expressed wishes regarding care and treatment goals . A record review of the comprehensive Care Plan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, record reviews, and facility policy review, the facility failed to ensure that tray line food temperatures were checked and documented prior to serving each meal for 15 days of 24 days of recorded temperatures reviewed for the month of March 2024. Findings include: Review of the facility's policy titled, Monitoring Temperature of Cooked Foods, with a revision date of 10/17, revealed . POLICY: The temperature of TCS (Time/Temperature Control) cooked foods will be monitored to ensure that the foods are not in the danger zone (above 41degrees F {Fahrenheit} and below135 degrees F) for more than 6 hours PROCEDURE: 2 . b. When food is placed in the hot holding equipment. The temperature of the food should be 135 degrees F or higher . On 03/25/24 at 9:40 AM, an initial tour of the kitchen with the Dietary Manager (DM) revealed several of the pages in the tray line temperature log binder, were incomplete or blank. The DM stated she expects staff to check tray line food temperatures and document the temperatures in the binder. She stated she recently did an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff and Resident Representative (RR) interviews, record review, and facility policy review, the facility failed to ensure a dependent resident received Activities of Daily Living (ADL) care, as evidenced by long thick toenails for one (1) of 16 sampled residents. (Resident #30) Findings include: Review of the facility's policy titles, ADL Care Policy, dated 8/23 revealed, POLICY It is the policy of this facility to provide appropriate treatment and services in relation to ADL care to residents to ensure all ADL needs are met on a daily basis, while attaining or maintaining the residence of highest, practicable, physical, mental, and social well-being . 2. The resident, to the extent possible, and /or the family/resident representative will be included in setting goals of care related to ADL's . On 3/25/24 at 10:46 AM, during an interview with the RR for Resident #30, she revealed she has concerned about the resident's toenails. She said the facility has failed to keep them cut. On 3/25/24 at 11:02 AM, in an observation and interview of Resident #30's toenails…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility policy review, the facility failed to inform a resident or Resident Representative (RR) of the risks and benefits of the use of bed rails prior to bed rail installation for one (1) of 16 sampled residents. (Resident #14) Findings include: Review of the facility policy titled, Physical Restraints, dated 2/20/2012, revealed, .Restraints shall only be used for the safety and well-being of the residents .1. Restraints will only be used with . the informed consent from the resident, physician and/or responsible party . 5. Practices that are not permitted include: a. Using bedrails to keep a resident from voluntarily getting out of bed as opposed to enhancing mobility while in bed On 3/25/24 at 10:30 AM, an observation revealed ¼ bedrails on the bed of Resident #14. The resident was not in bed and the bedrails were down. On 03/27/24 at 10:30 AM, during an interview and record review of the medical record with Licensed Practical Nurse (LPN) #1 confirmed Resident #14 did…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the facility's designated Hospice Coordinator coordinated the care provided by the Hospice service and the facility for one (1) of two (2) Hospice residents reviewed. (Resident #27) Findings include: A review of facility's policy titled, Hospice Program, dated 7/13/17, revealed, It is the policy of the facility to contract hospice services for residents who wish to participate in such programs .Procedure: 8. As the facility designee, the Director of Nursing, is responsible for working with hospice representatives to coordinate care to the resident provided by the facility staff and hospice staff. The Director of Nursing is responsible for the following: a. Collaborating with hospice and coordinating the facility staff participation in the hospice care planning process. b. Communicating with hospice staff participating in the care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the resident and family . On 03/25/24 at 1:26 PM, in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interviews, record reviews, and facility policy review, the facility failed to accurately complete Minimum Data Set (MDS) assessments for one (1) of 20 MDS assessments reviewed. Resident #23. Findings Include: Review of the facility's policy, MDS Assessment, dated 5/2006, revealed It is the policy of this facility to follow the RAI (Resident Assessment Instrument) process as set forth by CMS (Centers for Medicare/Medicaid) protocol. Record review of Resident #23's admission Record revealed the facility admitted her on 1/1/21 with diagnoses including Schizophrenia, Major Depressive Disorder, and Bipolar Disorder. Record review of the Pre-admission Screening (PAS) Application for Long Term Care dated 1/1/21 for Resident #23, revealed the question of Person has a diagnosis of a major mental illness? was answered with Yes which confirmed Resident #23 had a major mental illness upon admission. Record review of the facility's Order Summary Report for Resident #23 with active physician orders as of 2/11/22 revealed current physician orders for Divalproex Sodium…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record reviews, and facility policy review the facility failed to develop and implement the care plan related to catheter care, wound care, pain, and behaviors for three (3) of 20 care plans reviewed. Resident #9, Resident #54, and Resident #63. Findings include: Record review of the facility's policy, Comprehensive Care Plan, dated 10/2016, revealed .Policy Interpretation and Implementation 1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or resident representative, develop and maintains a comprehensive care plan for each resident .9. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: Resident #9 Record review of the facility's, Comprehensive Care Plan, revealed Resident #9 had a Foley catheter related to Neuromuscular dysfunction of the bladder which included an intervention to assure that a catheter strap is secured per protocol to prevent the tubing and leg bags from catching or pulling with the resident's regular movement. During an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interviews, record review, and facility policy review, the facility failed to clean a pressure wound in a manner to prevent the possible spread of infection for one (1) of four (4) pressure wound care observations. Resident #54 Findings Include: Record review of the facility's policy, Clean Dressing Change, undated, revealed It is the policy of the facility to provide wound care in a manner to decrease potential for infection and/or cross contamination .12. Cleanse the wound as ordered, taking care to not contaminate other skin surfaces or other surfaces of the wound (i.e clean outward from the center of the wound) . On 2/9/22 at 10:20 AM, the State Agency (SA) observed wound care to Resident # 54's right heel by Licensed Practical Nurse (LPN) #2 and assisted by Registered Nurse (RN) #3. During the observation, LPN #2 cleaned the wound with gauze and wiped in a circular motion from the center of the wound outward two times, using the same gauze. LPN #2 then disposed of the gauze and obtained clean gauze and repeated the same cleaning motion, wiping in a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review and facility policy review, the facility failed to anchor catheter tubing during catheter care to minimize movement or prevent possible friction or trauma and failed to ensure a catheter leg strap was in place for one (1) of three (3) catheter care observations. Resident #9. Findings Include: Review of the facility policy, Catheter Care Policy, dated 8/20 revealed It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care .Compliance Guidelines: . 12. wipe the catheter making sure to hold and secure the catheter in place to not pull on the catheter . Resident #9 Observation on 02/08/22 at 01:22 PM, of catheter care with Certified Nursing Assistant (CNA) # 2 revealed CNA #2 failed to secure the tubing on the catheter while providing catheter care. CNA #2 held the sides of the penis and pulled the tubing outward and did not hold the tubing secure. Resident #2 jumped when CNA #2 pulled on the tubing. Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record reviews and facility policy review the facility failed to prevent the possible spread of infection for one (1) of three (3) catheter care observations. Resident #59. Findings Include: Record review of the facilities Infection Prevention and Control Program dated 8/2017 revealed, It is a policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .4. Hand Hygiene Protocol a. All staff shall wash their hands when coming on duty, between resident contacts, after handling contaminated objects, after PPE (Personal Protective Equipment) removal, before and after eating, before and after toileting, and before going off duty. b. Staff shall wash their hands before and after performing resident care procedures. c. Hands shall be washed in accordance with our facilities established hand…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.