Inspection Reports for Communities of Wildwood Ranch
3222 SOUTH JOHN DUFFY DR, JOPLIN, MO, 64804-1569
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
111 residents
Based on a January 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 13, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the administration of blood pressure medication to a resident (Resident #22) outside the physician-ordered parameters.
Complaint Details
Complaint investigation found that Resident #22 received hydralazine HCl when systolic blood pressure was below the ordered parameter of 110 mm/Hg without documented physician approval or explanation. Staff interviews confirmed doses were administered outside parameters and documentation was missing.
Findings
The facility failed to ensure that blood pressure medication was administered according to physician orders, as staff administered hydralazine HCl to Resident #22 when the resident's systolic blood pressure was below the ordered threshold of 110 mm/Hg without documented physician approval. Interviews with staff confirmed the medication was given outside parameters without proper documentation or physician notification.
Deficiencies (1)
Failure to ensure each resident’s drug regimen was free from unnecessary drugs; blood pressure medication was administered outside physician-ordered parameters without documentation.
Report Facts
Resident ID: 22
Medication dosage: 50
Systolic Blood Pressure threshold: 110
Dates of medication administration outside parameters: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medicine Technician (CMT) 1 | Confirmed administration of medication outside parameters and lack of documentation | |
| Licensed Practical Nurse (LPN) 1 | Described procedure for holding medication and notifying physician if parameters not met | |
| Administrator, Director of Nursing (DON), and Regional Nurse Consultant | Confirmed policy that medication should not be given outside parameters unless physician contacted and documented |
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 1
Date: Jan 10, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident fall incident where the facility staff failed to ensure staff awareness and adherence to care planned fall interventions for a resident, resulting in injury.
Complaint Details
The investigation was complaint-driven, focusing on a resident who fell from bed due to staff not following fall prevention interventions. The resident sustained facial lacerations, hematomas, and skin tears, requiring hospital transfer. Staff interviews indicated lack of awareness of the resident's fall risk and care plan.
Findings
The facility failed to ensure an environment free from accident hazards and adequate supervision to prevent falls. Staff were unaware of or did not follow fall prevention care plans, leading to a resident falling from a raised bed and sustaining multiple injuries requiring hospital transfer. Interviews revealed staff lacked knowledge of the resident's fall risk and care plan details.
Deficiencies (1)
Facility staff failed to ensure staff were aware of and followed care planned fall interventions for a resident, resulting in a fall from a raised bed and injuries.
Report Facts
Facility census: 111
Resident admission date: Dec 24, 2022
Fall risk assessment date: Oct 13, 2023
Care plan revision dates: Care plan revised on 10/14/23, 10/18/23, 12/19/23, and 12/30/23
Incident dates: Resident fell on 12/19/23 and 12/30/23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN H | Licensed Practical Nurse | Documented resident fall and injuries, interviewed about incident |
| CNA D | Certified Nurse Aide | Raised resident bed and left resident unattended, interviewed about incident |
| LPN F | Licensed Practical Nurse | Interviewed about resident fall and staff knowledge |
| RN G | Registered Nurse | Updates care plans and interviewed about fall interventions |
| Director of Nursing | Director of Nursing (DON) | Interviewed about fall prevention policies and staff expectations |
| LPN B | Licensed Practical Nurse | Interviewed about resident fall history |
| CNA E | Certified Nurse Aide | Interviewed about staff leaving resident bed up and care plans |
| LPN C | Licensed Practical Nurse | Interviewed about fall reporting and care plan updates |
| Administrator | Administrator | Interviewed about staff communication and fall interventions |
| Medical Director | Medical Director | Interviewed about expectations for staff awareness of fall risks |
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 1
Date: Dec 7, 2023
Visit Reason
The inspection was conducted following a complaint regarding a resident being transferred via slide transfer during a facility evacuation without ensuring the area was free from hazards, resulting in the resident's leg getting caught in a blanket and causing pain.
Complaint Details
The complaint investigation found that Resident #1 was transferred by slide transfer during an emergency evacuation without ensuring the area was free of hazards, resulting in the resident's leg getting caught in a blanket and causing pain. The resident reported pain rated ten out of ten when moved. Staff were unaware of emergency transfer protocols and used slide transfer due to unavailability of mechanical lift.
Findings
The facility failed to ensure all residents were free from accident hazards during transfers. Specifically, Resident #1 was slide transferred during an emergency evacuation, and staff did not ensure the transfer area was free of hazards, resulting in the resident's leg getting caught in a blanket causing pain. The resident had continued pain despite an unremarkable x-ray. Staff interviews revealed lack of knowledge of emergency transfer protocols and that the Hoyer lift was unavailable at the time.
Deficiencies (1)
Failed to ensure a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents during resident transfer.
Report Facts
Census: 109
Residents affected: 1
Staff involved: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurses Assistant (CNA) A | Certified Nurses Assistant | Stated resident is totally dependent on staff for transfers |
| Registered Nurse (RN) B | Registered Nurse | Assisted with transfer during evacuation and provided details on transfer |
| Licensed Practical Nurse (LPN) C | Licensed Practical Nurse | Assisted with transfer during evacuation and described transfer circumstances |
| Certified Nurses Assistant (CNA) D | Certified Nurses Assistant | Present during transfer and commented on appropriateness of slide transfer |
| Director of Nursing (DON) | Director of Nursing | Unaware of slide transfer until after evacuation; discussed transfer safety and assessment |
| Administrator | Administrator | Commented on emergency transfer methods and staff responsibilities |
Inspection Report
Routine
Census: 103
Deficiencies: 3
Date: Jul 28, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to staff background checks, resident bed-hold policies during hospital transfers, and safety measures to prevent resident elopement and accidents.
Findings
The facility failed to complete required criminal background checks and registry verifications prior to employment for several staff members. The facility also failed to provide written bed-hold policy notices to residents or their representatives upon hospital transfers. Additionally, the facility did not ensure proper functioning and monitoring of wander guard alarms, resulting in a resident exiting the building undetected for a short period.
Deficiencies (3)
Failure to implement policies and procedures to prevent abuse by ensuring required criminal background checks, employee disqualification list checks, and CNA registry checks were completed prior to employment for multiple staff members.
Failure to notify residents or their representatives in writing about the facility's bed-hold policy during hospital transfers for four residents.
Failure to provide adequate supervision and ensure wander guard alarms functioned properly, resulting in a resident exiting the building and the alarm not being heard on all halls or pagers.
Report Facts
Facility census: 103
Days delay in background checks: 11
Days delay in background checks: 5
Days delay in background checks: 6
Days delay in background checks: 2
Days delay in background checks: 1
Days delay in background checks: 142
Residents affected by bed-hold policy failure: 4
Wander guard checks missed: 3
Resident off floor time: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Named in deficiency related to delayed background checks |
| LPN D | Licensed Practical Nurse | Named in deficiency related to delayed background checks |
| SS A | Social Services | Named in deficiency related to delayed background checks |
| Office Staff C | Named in deficiency related to delayed background checks | |
| COTA F | Certified Occupation Therapy Assistant | Named in deficiency related to delayed background checks |
| CNA E | Certified Nurse Aide | Named in deficiency related to delayed background checks |
| LPN H | Licensed Practical Nurse | Interviewed regarding bed-hold form procedures and nursing responsibilities |
| RN Q | Registered Nurse | Interviewed regarding bed-hold form procedures |
| LPN R | Licensed Practical Nurse | Interviewed regarding bed-hold form procedures |
| Social Services Director | Interviewed regarding transfer notices and bed-hold policy communication | |
| Assistant Director of Nursing | Interviewed regarding hospital transfer procedures and bed-hold policy | |
| CNA L | Certified Nurses Aide | Interviewed regarding elopement incident and alarm system |
| CNA M | Certified Nurses Aide | Interviewed regarding elopement incident and alarm system |
| Certified Medication Technician S | Interviewed regarding resident elopement risk and wander guard use | |
| Certified Nurses Aid K | Interviewed regarding resident elopement risk and wander guard use | |
| Licensed Practical Nurse O | Interviewed regarding residents wearing wander guard devices | |
| Administrator | Interviewed regarding staff responsibilities for wander guard alarms | |
| Director of Nurses | Interviewed regarding staff responsibilities for wander guard alarms |
Inspection Report
Annual Inspection
Census: 91
Deficiencies: 6
Date: Jan 24, 2020
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federally mandated comprehensive and quarterly Minimum Data Set (MDS) assessments, respiratory care standards, bed rail safety, and medication administration.
Findings
The facility failed to complete timely annual and quarterly MDS assessments for multiple residents, failed to transmit a Death in Facility MDS record timely, failed to ensure proper respiratory care including CPAP and oxygen equipment management, failed to complete required assessments and obtain consent for bed rail use, and had a medication error rate exceeding 5% due to incorrect medication dosing and improper inhaler administration.
Deficiencies (6)
Failed to complete annual Minimum Data Set (MDS) assessments within required timeframes for three residents.
Failed to complete quarterly Minimum Data Set (MDS) assessments within required timeframes for four residents.
Failed to transmit a Death in Facility Minimum Data Set (MDS) record within required timeframe for one resident.
Failed to ensure proper cleaning, physician orders, diagnosis documentation, and care planning for CPAP and oxygen equipment for two residents.
Failed to complete side rail assessments, risk/benefit reviews, obtain informed consent, and document bed rail measurements for four residents using bed rails.
Medication error rate exceeded 5% due to failure to administer correct dose of medication and improper inhaler administration for one resident.
Report Facts
Residents sampled: 19
Facility census: 91
Medication error rate: 7.14
Medication administration opportunities: 28
Medication errors: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse B | Licensed Practical Nurse | Reviewed resident medical records and medication orders; interviewed regarding CPAP and medication administration |
| MDS Coordinator C | MDS Coordinator | Interviewed regarding delays in MDS assessments and submissions |
| Director of Nursing | Director of Nursing | Interviewed regarding oxygen and CPAP orders, bed rail procedures, and medication administration expectations |
| Director of Therapy Services | Director of Therapy Services | Interviewed regarding bed rail evaluation and installation process |
| Certified Medication Technician A | Certified Medication Technician | Observed administering medications including inhalers |
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