WILMOT, SD - Federal inspectors discovered a serious electrical safety hazard at Wilmot Care Center when they found water actively leaking from a whirlpool tub directly onto electrical components, creating conditions that posed immediate danger to residents and staff.
Immediate Jeopardy Violation Discovered During Inspection
On March 6, 2025, Centers for Medicare & Medicaid Services surveyors conducting a routine inspection at the 23-bed facility uncovered what they classified as an "immediate jeopardy" situation - the most severe category of nursing home violations. The dangerous conditions centered around the facility's whirlpool tub, which had been leaking water onto a 120-volt electrical box and surrounding electrical components.
During their morning inspection at 7:57 a.m., surveyors documented multiple safety hazards in the bathing room. Water was actively dripping behind the electrical control panel, creating standing water that covered the floor beneath electrical wires and components. A yellow electrical cord that powered the whirlpool system was found lying in the standing water, creating a significant electrocution risk.
The inspection revealed alarming conditions including: - Active water leak directly behind the 120-volt electrical box - Standing water covering the floor under electrical wiring - Electrical cord submerged in standing water - Unidentified green substance on PVC piping - Corroded cake pan placed under pipes to catch water - Rusted metal frame with chipping paint
Staff Aware of Problem for Months
The inspection uncovered that facility staff had been aware of the leaking problem for an extended period. Certified nursing assistant F, who served as the facility's bath aide, told inspectors she had been reporting the leak to the maintenance supervisor "on several different occasions" but had never filed a formal work order.
"I typically have a mop in here to mop up all the water in between giving baths to residents," the aide reported to inspectors. She explained that when she started working as a bath aide in November 2024, the whirlpool was broken and unusable. After repairs in December 2024, she began using the tub again but noticed the persistent leaking problem.
The maintenance supervisor confirmed he had received multiple verbal reports about the leak but admitted he "may have forgotten about that because it had not been written down on the maintenance log sheets."
Administrative Leadership Unaware of Hazard
Perhaps most concerning was that both the facility administrator and director of nursing were completely unaware of the dangerous electrical conditions when inspectors arrived. When brought to the scene at 8:28 a.m., neither administrator A nor director of nursing B knew about the active leak occurring directly behind the electrical components.
The director of nursing mentioned that "sometimes the whirlpool tub shuts down on its own," which may have been an indication of electrical problems caused by water infiltration. However, this intermittent shutoff apparently did not trigger a comprehensive safety inspection of the equipment.
Understanding the Electrical Risks
Water and electricity create an extremely dangerous combination in healthcare settings. When electrical components become wet, they can cause several life-threatening situations:
Electrocution hazards occur when electrical current finds a path through water to a person's body. In a bathing environment, residents are particularly vulnerable because wet skin dramatically reduces electrical resistance, allowing dangerous current to flow through the body more easily.
Electrical fires can result when water causes short circuits in wiring or control panels. These fires can spread rapidly and produce toxic smoke, posing additional risks to residents who may have limited mobility.
Equipment malfunctions caused by water damage can lead to unpredictable behavior of electrical systems, potentially trapping residents in dangerous situations or causing injury during equipment operation.
Immediate Response and Corrective Actions
Once inspectors identified the immediate jeopardy, facility leadership took swift action to eliminate the danger. At 8:45 a.m., the administrator directed maintenance staff to unplug the electrical cord powering the whirlpool system.
By 1:28 p.m. that same day, administrators had taken additional safety measures by cutting the electrical cord in half, ensuring the whirlpool could not be inadvertently powered on. The facility also placed "Out of Order" signs on both the tub room door and the equipment itself, emptied the water reservoir, and shut off water supply to prevent future accumulation.
At 1:45 p.m., after verifying these corrective measures, the survey team determined the immediate danger had been eliminated, allowing the inspection to continue.
Additional Safety and Care Violations
The inspection also revealed problems beyond the electrical hazard. Surveyors found issues with infection control practices, food safety, and nutritional services that affected multiple residents.
Infection Control Failures: Staff were not properly implementing enhanced barrier precautions for residents with MRSA infections or indwelling catheters. One resident with an MRSA-positive wound reported that staff only used gloves during wound care but not for other close-contact activities like bathing or transfers.
Food Safety Concerns: The kitchen contained multiple expired food items, including milk, cheese, and condiments past their expiration dates. Rotting tomatoes and moldy produce were found in the walk-in cooler, while unlabeled food containers violated the facility's own storage policies.
Nutritional Shortcomings: On March 4, residents did not receive the complete approved menu when coleslaw was missing from the lunch service. Kitchen staff failed to substitute an equivalent vegetable, leaving residents with incomplete nutritional requirements for the meal.
Industry Standards and Compliance Requirements
Federal regulations require nursing homes to maintain safe physical environments and ensure all equipment functions properly. Facilities must have comprehensive maintenance programs that identify and address potential hazards before they create dangerous conditions.
Proper electrical safety protocols should include regular inspections of all electrical equipment, immediate isolation of damaged systems, and formal documentation of all maintenance issues. Staff should be trained to recognize electrical hazards and report them through established channels.
Effective communication systems between frontline staff and management are essential for identifying problems early. The breakdown in reporting at Wilmot Care Center, where verbal reports were forgotten due to lack of written documentation, represents a significant gap in safety procedures.
Systemic Management Challenges
The violations at Wilmot Care Center appear to reflect broader management and oversight issues. The administrator acknowledged "many ongoing frustrations with the kitchen and food service" and noted that the previous dietary manager had left at the end of 2024 after training current staff members.
These staffing transitions and management challenges may have contributed to the facility's difficulty maintaining consistent safety standards across multiple departments. When leadership attention is divided among various operational problems, critical safety issues can go unaddressed until they reach crisis levels.
The facility has committed to implementing weekly inspections of the whirlpool area once a new unit is installed, along with enhanced staff education on proper work order procedures to ensure maintenance issues are formally documented and tracked.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wilmot Care Center Inc from 2025-03-06 including all violations, facility responses, and corrective action plans.
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