Wilson Pines Nursing and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and Responsible Party (RP) and staff interviews, the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Form 10055- Skilled Nursing Facility (SNF) Advanced Beneficiary Notification (ABN) and Form 10123-Notice of Medicare Non-Coverage (NOMNC) when the facility initiated discharge from Medicare Part A Services when benefit days were not exhausted. This was for 1 of 3 residents (Resident #31) reviewed for beneficiary notice protection. Findings included: Resident #31 was admitted to the facility on [DATE] under Medicare Part A covered skilled services. Resident #31's Medicare Part A covered skilled services ended on 1/22/25. He remained in the facility. A review of Resident #31's medical record revealed no evidence Resident #31 was provided with a CMS SNF-ABN and a CMS NOMNC form. On 4/8/25 at 1:49 PM an interview with the Business Office Manager (BOM) indicated Resident #31's Medicare Part A covered skilled services began on 11/20/24. She stated when these covered…

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 2. Resident #46 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease. A review of a Physician order dated 3/12/25 revealed an order for Resident #46 to receive dialysis Monday, Wednesday, and Friday at an offsite dialysis clinic. The admission Minimum Data Set (MDS) assessment dated [DATE] was not coded for dialysis. In an interview with the MDS Coordinator on 4/9/25 at 11:39 am she stated she was aware Resident #46 received dialysis. The interview further revealed that the MDS Coordinator routinely reviewed hospital discharge summaries and coded the MDS based on the reviews. The MDS Coordinator stated Resident #46 should have been coded for dialysis on the 3/13/25 MDS and the failure to do so had been an oversight. In an interview with the Administrator on 4/9/25 at 3:06 pm he stated the MDS completed on 3/13/25 should have captured that Resident #46 received dialysis. Based on record review and staff and Responsible Party interviews, the facility failed to accurately code…

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, record review and staff interviews the facility failed to implement their infection control practices and procedures when the facility Staff Development Coordinator (SDC) failed to don a gown before entering the room of a resident on Contact Precautions. The facility also failed to implement their policy for Enhanced Barrier Precautions (EBP) when Nurse #1 failed to wear a gown before entering a resident's room to provide medications via a gastrostomy tube (tube inserted directly into the stomach through a small hole in the abdomen to administer hydration, nutrition and medication). The deficient practice occurred for 2 of 20 staff (SDC and Nurse #1) observed for infection control practices. Findings included: 1. Review of the facility policy titled Contact Precautions dated 4/2023 and revised on 6/13/24 stated in part: contact precaution recommendations include wearing a gown when entering room and caring for the resident. Review of the signage on the door to Resident #36's room read in part, Contact precautions, everyone must: wear a gown when entering 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.

Based on observations and staff interviews the facility failed to dry dishes individually by nesting (stacking dishes/utensils of the same size without an air gap) 4 deep dish pans and 2 large metal mixing bowls, while still wet, on the drying rack for 1 of 3 kitchen observations. Findings included: During observation on 3/3/24 at 10:24 AM 4 deep dish pans and 2 large metal mixing bowls were observed nested on the drying rack. Upon requesting Dietary [NAME] #1 to remove the top dish, water was visible on the surfaces of the dishes nested together. During an interview on 3/3/24 at 10:24 AM Dietary [NAME] #1 stated the 4 deep dish pans, and 2 large metal mixing bowls were left over from last night to dry on the drying rack. She did not know why they had been nested in each other. Upon observing the stack of deep-dish pans and large metal mixing bowls, and separating them, she stated the dishes were still wet from last night because they were nested. She further stated staff should not nest dishes that were drying because moisture could be trapped and could cause contamination. During…

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 interview the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor interventions that the committee had previously put in place following the recertification and complaint surveys of 8/27/21 and 2/16/23. This was for a recited deficiency in the area of Food and Nutrition Services (F812). The continued failure during three federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program. The findings included: This tag is cross referenced to: F812: Based on observations and staff interviews the facility failed to dry dishes individually by nesting (stacking dishes/utensils of the same size without an air gap) 4 deep dish pans and 2 large metal mixing bowls, while still wet, on the drying rack for 1 of 3 kitchen observations. During the recertification and complaint survey of 8/27/21 the facility failed to maintain sanitary conditions in the kitchen by: 1. failing to ensure the dishwasher was rinsing dishes at the correct temperature to sanitize…

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 revise the care plan to reflect the discontinuation of hospice care. This was for 1 of 2 residents (Resident #30) reviewed for hospice and end of life care. Findings included: Resident #30 was admitted to the facility on [DATE] with a diagnosis of dementia. A review of the significant change Minimum Data Set (MDS) assessment for Resident #30 dated 12/15/23 revealed he was not receiving hospice care. A review of Resident #30's care plan dated last revised on 12/28/23 revealed in part a focus area initiated on 9/5/23 and last revised on 12/27/23 for hospice care. The goal was for Resident #30 to be free from pain through the next review. An intervention was spiritual care consult. On 3/4/24 at 2:40 PM an interview with Nurse #1 indicated she was the resource nurse. She stated Resident #30 had been receiving hospice care, but this had been discontinued on 12/8/23. On 3/4/24 at 3:04 PM an interview with MDS Nurse #1 indicated she completed 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.

Based on record review, observations and staff interviews, the facility failed to (1) label foods items with an open and expiration date and discard expired food items stored for use in 1 of 1 walk-in refrigerator for 1 of 2 kitchen observations and (2) label food items with an open and expiration date stored for use in 1 of 1 walk-in freezer. These practices had the potential to affect food served to 99 of the 99 residents. Finding included: 1. On 2/13/2023 at 9:48 a.m. in the initial tour of the kitchen accompanied by Dietary Manager (DM), the following items were observed in the walk-in refrigerator: Two containers of frozen solid puree bacon in a box with no date indicating when opened or an expiration date. The Dietary Manager discarded the item. A large, opened container of ranch buttermilk dressing dated open 12/1/2022. There was no expiration date on the manufacture's label or the container. The Dietary Manager stated opened containers of dressing expired one month after opening and discarded the ranch buttermilk dressing. An unopened 12-pack of boiled eggs indicating no…

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 interview the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor interventions that the committee had previously put in place following the recertification and complaint survey of 8/27/21. The deficiencies are in the areas of Accuracy of Assessments (641), Accidents (689), Label/Store Drugs and Biologicals (761), and Food Procurement (812). The continued failure during two federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program. Findings included: This tag is cross referenced to: F641: Based on record review, observations and staff interviews, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for isolation (Resident #243), use of a wander guard (Resident #6), for dementia (Resident #58) and discharge status (Resident #90) for 4 of 25 residents whose MDS assessments were reviewed. During the recertification and complaint survey of 8/27/21, the facility was cited for accurately coding an admission…

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 resident, family and staff interviews the facility failed to treat a resident with dignity and respect by speaking harshly to her and asking the resident if she had been playing in her poop for 1 of 5 residents reviewed for dignity (Resident #346). Findings included: Resident #346 was admitted to the facility on [DATE] with diagnosis of hypertensive chronic kidney disease Stage 5 and a history of falls. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #346 had moderately impaired cognition. She required extensive assistance from staff with toileting. She was frequently incontinent of bowel and bladder. Review of the care plan dated 02/10/23 for Resident #346 included, in part, the following focal area: At risk for unmet needs and/or compromised dignity. The goals for Resident #346 were to maintain dignity and have decreased episodes of anxiety. Interventions included, in part, to talk with resident in a low pitch, calm voice. In an interview with Resident #346 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice and CMS-10123 Notice of Medicare Non-Coverage (NOMNC) (Resident #65) and failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (Resident #15) prior to discharge from Medicare Part A skilled services for 2 of 3 residents reviewed for beneficiary protection notification review. The findings included: 1. Resident #65 was admitted to the facility on [DATE]. Resident #65's Medicare Part A skilled services ended on 12/9/22. She remained in the facility. Record review revealed that Resident #109 was not given the CMS-10555 Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) or CMS-10123 Notice of Medicare Non-Coverage (NOMNC). During an interview with the Business Office Manager on 2/13/23 at 3:04 PM she reported she was unable to locate the required forms for…

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, observations and staff interviews, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for isolation (Resident #243), use of a wander guard (Resident #6), diagnosis of dementia (Resident #58) and discharge status (Resident #90) for 4 of 25 residents whose MDS assessments were reviewed. Findings included: 1. Resident #243 was admitted to the facility on [DATE]. Nursing documentation dated 1/30/2023 at 9:37 p.m. revealed the physician and the Resident #243's representative was notified Resident #243 tested positive for COVID-19. Resident #243's care plan dated 1/30/2023 included a focus for an infection related to COVID-19 that was resolved on 2/13/2023. Physician notes dated 1/31/2023 indicated Resident #243 was diagnosed with COVID-19. An infection note documented in Resident #243's medical record dated 1/31/2023 at 9:40 a.m. indicated the day of onset for COVID-19 was 1/30/23, and the type of transmission based precautions (isolation) required was contact and…

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, staff interview and record review the facility failed to implement interventions for fall prevention for a resident with a history of falls for 1 of 2 residents reviewed for accidents (Resident #346). Findings included: Resident #346 was admitted to the facility on [DATE] with diagnoses that included falls, osteoarthritis, and restless leg syndrome. Review of a health status note written on 01/31/23 at 12:52 AM documented: PT [Physical Therapy] walked past resident's room and found resident on the bathroom floor . [Resident #346 was] reeducated to use call bell when needing to ambulate, to lock (wheelchair) when transferring, and to wear non-skid footwear. Quality Assurance-Falls Review (at risk for or actual) dated 2/2/23 was reviewed and documented Resident #346 had a fall on 01/03/23. Resident had non-skid (gripper) socks to feet when she fell. She was reminded to call for assistance. Interventions included to place call bell within reach, place bed in lowest position, and continue…

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, resident interview, family interview, staff interviews and record review, the facility failed to provide a lunchtime meal to a dialysis resident on 02/01/23, 02/03/23, 02/06/23, 02/08/23, 02/10/23 and 02/13/23 for 1 of 2 residents reviewed for dialysis (Resident #346). Findings included: Resident #346 was admitted to the facility on [DATE] with diagnoses that included hypertensive chronic kidney failure Stage 5. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #346 had moderately impaired cognition. She received hemodialysis. In an interview with Resident #346 on 02/14/23 at 2:30 PM she stated she had not gotten a lunch meal either at the facility or boxed to go since her admission on [DATE]. She reported she went to dialysis every Monday, Wednesday, and Friday. She explained her chair time at dialysis was 11:30 and she was usually transported between 10:30 and 11:00 each dialysis day. She reported her family had told staff she was not receiving 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 observation and staff interviews the facility failed to keep medications secured by storing opened and unlabeled medications in four different medications cups in the medication cart on the 600 hall for 1 of 2 medication carts inspected. Findings included: An inspection of the 600 hall medication cart on 02/16/23 at 9:45 AM revealed four separate medications cups stored in a drawer on the cart that contained the following unlabeled items: a cup containing 9 pills, a cup of a white liquid, a cup with brown applesauce, and a cup of clear gel. In an interview with Medication Aide #1 on 02/16/23 at 9:45 AM she stated she had opened some of the medications to administer to a resident who refused to take the medications at that time. She reported the resident had told her he was going to the store and would be back in a minute. She stated she finished opening the rest of the medications due at that time and placed the unlabeled mediations in the drawer to administer when the resident returned. She was not able to identify the pills in the cup without looking at the Medication…

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.