Wilkes Regional Medical Ctr Sn

Based on observations and staff interviews, the facility failed to: (1) remove expired items from 1 of 1 reach in cooler; (2) provide an open/ use by date for food available for use in 1 of 1 walk in refrigerators and 2 of 2 walk in freezers; (3) maintain dishware that was stacked wet and available for use; and (4) keep dishes free from dried debris available for use. This deficient practice had the potential to affect eight (8) of eight (8) residents. The findings included: a. On 4/21/25 at 11:45 AM with the Kitchen Supervisor, one half gallon of whole milk was observed with an expiration date of 04/18/25 and was available for use in the reach in cooler. b. Observation of the kitchen occurred on 4/21/25 at 11:45 AM with the Kitchen Supervisor. The reach in cooler had food open to air and no use by date which included broccoli, shredded chicken and sausage and gravy. The walk-in refrigerator had the following food with no open or use-by date: one package of American cheese, one package of pepper jack cheese, half of a 5-pound (lb.) bag of carrots, and one 5 lb. container of pimento…

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 and staff interviews, the facility failed to keep the area around the garbage compactor free of accumulated trash and debris for 1 of 1 garbage compactor observed. The findings included: An observation was completed on of the garbage compactor area on 4/21/2025 at 12:40 PM. The observation revealed the following items outside of the garbage compactor: 1 medium black plastic bag of trash, multiple blue latex gloves, 1 tin can, 2 dented hazard cones, 1 empty syringe, 1 small container of unidentified food. A large gray bag of trash and large brown box was sitting on the loading dock where the garbage compactor was located. An interview with the Kitchen Supervisor on 4/21/2025 at 1:00 PM revealed the garbage compactor was used by the whole hospital. The Kitchen Supervisor was not aware that the garbage area was the responsibility of Kitchen Services. An interview with the Nutritional Service Manager on 4/22/2025 at 11:40 AM revealed she was unaware that the garbage area was the responsibility of Kitchen Services. An interview with the Nurse Manager was completed on…

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 record review and staff interviews, the facility failed to implement an infection surveillance plan for monitoring and tracking infections in the facility. This practice had the potential to affect 8 of 8 residents in the facility. Findings included: The facility's Infection Prevention and Control Surveillance policy dated 2/1/25 documented the Infection Preventionist (IP) conducts surveillance of all infections among residents and partners including tracking and analysis of outbreaks of infections. Record review indicated Resident #2 receiving antibiotics for osteomyelitis and Resident #4 receiving antibiotics for a wound infection. The Infection Preventionist (IP) nurse was interviewed on 4/23/25 at 9:15 AM. The IP nurse discussed tracking and analyzing infections in the skilled nursing unit by using an approved tracking form. She explained the form was computerized, so she did not have a paper copy for review. IP provided computerized information for five infections that were regularly tracked, Central Line associated bloodstream infection, catheter associated urinary…

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 record review and staff interviews, the facility failed to document education was provided in the medical record regarding the benefits and potential side effects of the influenza and pneumonia vaccines. This occurred for 3 of 5 residents (Resident #210, Resident #110, and Resident #159) reviewed for vaccines. The findings included: a. Resident #210 was admitted to the facility on [DATE]. The admission Minimum Data Set assessment dated [DATE] showed the resident to be cognitively intact. The resident's immunization record was reviewed and revealed that flu vaccine was current, but the resident was due the pneumonia vaccine and Resident #210 had declined the pneumonia vaccine. The immunization record review also revealed that nothing was documented under the education notes section on the immunization record. Interview with Resident #210 on 4/22/25 at 2:45 PM revealed she declined any additional pneumonia vaccine, and she reported her flu vaccine was up to date. She reported she did not remember being…

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 record review, resident, and staff interviews, the facility failed to document that education was provided in the medical record regarding the benefits and potential side effects of the COVID-19 vaccines. This occurred for 4 of 5 residents reviewed for immunizations (Resident #210, Resident #110, Resident #159, Resident #4). The findings included: a. Resident #210 was admitted to the facility on [DATE]. The admission Minimum Data Set assessment dated [DATE] showed the resident to be cognitively intact. The Resident's immunization record was reviewed and revealed that the resident had declined the covid vaccine. The immunization record review also revealed that nothing was documented under the education notes section on the immunization record for this vaccine. An interview with Resident #210 was conducted on 4/22/25 at 2:45 PM and revealed she declined any additional covid vaccines and she did not remember being educated on the risk of her not receiving them. b. Resident #110 was admitted to the…

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 record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for the use of oxygen for 1 of 8 residents (Resident #109) whose MDS assessments were reviewed. The findings included: Resident #109 was admitted to the facility on [DATE] with diagnosis that included chronic obstructive pulmonary disease (COPD). A review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #109 was cognitively intact. The MDS indicated diagnosis of COPD and was not coded for oxygen use. A review of Resident #109's orders revealed oxygen care orders: - (4/8/25) Nasal Cannula 1 liter per minute, keep oxygen saturation greater than 92% - (4/8/25) Pulse oximetry, continuous, maintain oxygen saturations greater than 94% An interview with the MDS Coordinator on 4/23/25 at 10:43 AM revealed respiratory orders should be addressed on admission by including them in assessments and care plans. MDS Coordinator did not say why the oxygen was not coded.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, the facility failed to develop a baseline care plan that addressed a resident's oxygen and respiratory care for 2 of 3 residents reviewed for baseline care plans (Resident #109 and Resident #110). The findings included: 1. Resident #109 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis that included chronic obstructive pulmonary disease (COPD). A review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #109 was cognitively intact. The MDS also indicated diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and was not coded for oxygen. A review of Resident #109's active care plan dated 4/8/2025 revealed there were no goals or interventions regarding oxygen or respiratory care included in the baseline care plan. An interview with Nurse #1 on 04/22/25 at 01:22 PM stated orders and care plans were reviewed by the nurse each shift. Nurse #1 confirmed Resident #109 was receiving oxygen and respiratory status was…

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 observations, record review and staff interviews, the facility failed to follow physician orders for 1 of 1 resident (Resident #209) reviewed for professional standards of practice. The findings included: Resident #209 was admitted to the facility on [DATE] with a diagnosis that included Diabetes, and bilateral leg swelling. A review of the admission Statement submitted by Nurse #1 on 4/18/2025 revealed Resident #209 was alert, disoriented to place, time, person, and event, speech was clear, and cognition level was appropriate for attention/concentration. At the time of review no behaviors had been identified. A review of the physician orders dated 4/18/25 revealed a treatment for no-sting barrier film to the right heel, heel floating boot placed on resident, and float heels always. A review of the Baseline Care Plan dated 04/18/2025 revealed a problem as skin integrity. The goal listed was that skin integrity would improve with the interventions of providing skin care and provide pressure relieving…

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 observations, record review, and staff interviews, the facility failed to post cautionary and safety signage outside resident rooms that indicated the use of oxygen and failed to follow Physicians orders related to oxygen use for 2 of 2 residents reviewed for respiratory care (Resident #109, and Resident #110). The findings included: A. Resident #109 was admitted to the facility on [DATE] with diagnosis that included chronic obstructive pulmonary disease (COPD). A review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #109 was cognitively intact. The MDS indicated diagnosis of COPD and was not coded for oxygen use. A review of Resident #109's active care plan dated 4/8/2025 revealed there were no goals or interventions regarding oxygen or respiratory care included in the baseline care plan. Resident #109's April 2025 oxygen assessment flowsheet for nursing revealed all nursing staff documented oxygen flow rate was 2 liters per minute and completed a spot check for oxygen level. 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 record reviews and Consultant Pharmacist interviews, the Consultant Pharmacist failed to communicate to the facility the need to limit the use of a psychotropic drug (drug that affects the mental state) ordered as needed to 14 days for 1 of 5 residents reviewed for unnecessary medications (Resident #2). The findings included: Resident #2 was admitted to the facility on [DATE] with a diagnosis of anxiety disorder. The physician order dated 12/11/24 read, Ativan (antianxiety) 0.5 milligrams (mg) by mouth twice daily as needed for anxiety with a start date of 12/12/2024 for a duration of 14 days (12/26/24). Review of January 2025 MAR revealed Resident #2 received Ativan 0.5 mg by mouth each night from 01/01/25 through 01/31/25. The Pharmacy Consultant's drug regimen review dated 1/13/25 included no recommendations for a stop date for Ativan 0.5 mg and there was no clinically significant medication issues identified. Review of February 2025 MAR revealed Resident #2 received Ativan 0.5 mg by mouth each night…

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 record reviews, staff, Consultant Pharmacist, and Nurse Practitioner interviews, the facility failed to correctly enter an as needed psychotropic (drug that affects the mental state) medication order to include the 14 day stop date for 1 of 5 residents reviewed for unnecessary medications (Resident #2). The findings included: Resident #2 was admitted to the facility on [DATE] with a diagnosis of anxiety disorder. The physician order dated 12/11/24 reviewed for Resident #2 revealed an order for Ativan (antianxiety) 0.5 milligrams (mg) by mouth twice daily as needed for anxiety with a start date of 12/12/2024 for a duration of 14 days (12/26/24). Review of the December 2024 Medication Administration Record (MAR) revealed Resident #2 received Ativan 0.5 mg by mouth each night from 12/11/24 through 12/27/24. He did not receive it on 12/29/24. He did receive it on 12/30/24 and 12/31/24. Review of January 2025 MAR revealed Resident #2 received Ativan 0.5 mg by mouth each night from 01/01/25 through 01/31/25.…

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 observations, record review and staff, and Nurse Practitioner interviews the facility failed to complete an advance directive when the resident elected Do Not Attempt Resuscitate (DNAR) status with limited scope of treatment for 1 of 8 residents reviewed for advance directives (Resident #11). The findings included: Resident #11 was admitted to the facility on [DATE]. No Minimum Data Set (MDS) information was available. Review of a physician order dated 03/29/24 read: DNAR with limited scope of treatment. If the patient has no pulse and is not breathing: Do Not Attempt Resuscitation. If patient has pulse and/or is breathing but condition is deteriorating, limited scope of treatment. Do use medical treatment determined by the treatment team to be appropriate. These treatments may include vasopressors and other medications, intravenous (IV) fluids medications, cardiac monitoring, and synchronized cardioversion. Do consider use of less invasive airway support such as bilevel positive airway pressure (bipap)…

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 observations, record review and staff and resident interviews, the facility failed to post cautionary and safety signs that indicated the use of oxygen for 1 of 1 resident reviewed for respiratory care (Resident #14). The findings included: Resident #14 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD) and chronic respiratory failure with hypoxia. A review of Resident #14's admission Minimum Data Set assessment was unable to be completed due to Resident #14's recent admission to the facility. Review of Resident #14's physician orders revealed an order for oxygen delivered via nasal cannula at 5 liters per minute (lpm) continuously. An observation of Resident #14 on 04/09/24 at 11:33 AM revealed he was in his room, sitting in his wheelchair, watching television. Resident #14 was observed with a nasal cannula with oxygen being delivered at 5 lpm. There was no cautionary or safety signs noted in Resident #14's room, his door, or anywhere in his…

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 observations, record reviews, resident, staff, and Nurse Practitioner interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification survey conducted on [DATE]. This failure was for one deficiency that was originally cited in the area of Resident Rights (F578) that was subsequently recited on the current recertification survey of [DATE]. The repeat deficiency during two federal surveys of record showed a pattern of the facility's inability to sustain an effective QA program. The findings included: This tag is cross referred to: F578: Based on observations, record review, staff, and Nurse Practitioner interviews the facility failed to complete an advance directive when the resident elected Do Not Attempt Resuscitate (DNAR) status with limited scope of treatment (Resident #11) for 1 of 8 residents reviewed for advance directives. During the recertification of [DATE]…

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.