Susanna Wesley Health Center

Inspectors wroteBased on observations, record reviews, and interviews, it was determined that the facility did not maintain a safe environment free from potential accident and hazards and did not provide sufficient supervision to prevent potential accidents for 1 of 24 sampled residents (Resident #23). Resident #23 was left unsupervised with an unsecured disposable razor placed on the bedside nightstand for several hours. This lapse in protocol elevated the risk for Resident #23 to experience injuries such as cuts, which could result in infection or other medical complications. At the time of the survey, there were 119 residents residing in the facility.

Inspectors wroteBased on observations, interview and record reviews, the facility's Quality Assurance and Assessment (QAA)/QAPI) committee failed to demonstrate that an effective plan of action was implemented to correct identified quality deficiencies in the problem area related to repeated deficient practice for F689 - Free of Accident Hazards/Supervision/Devices. The facility was cited for F689 on 6/12/2025. The repeated deficient practice had the potential to affect any of the 119 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to protect residents' information on the third floor as evidenced by, an observation of a computer screen unattended with residents' information visible and easily accessible. There were 118 residents residing in the facility at the time of survey.

Inspectors wroteBased on observations, interviews and record review the facility failed to code a Minimum data set that accurately reflects resident's status for one (Resident #275) out of one sampled resident as evidenced by the MDS not coded for indwelling urinary catheter, despite Resident #275 having an indwelling urinary catheter since admission. There were seven residents with indwelling urinary catheter at the time of the survey.

Inspectors wroteBased on observations, record review and interviews, the facility failed to revise a tube feeding care plan for one (Resident #97) out of one sampled resident as evidenced by the care plan interventions included abdominal binder despite no physician order for an abdominal binder. There were nine residents with tube feedings at the time of survey.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide supervision to prevent accident hazards for one (Resident #275) out of one resident sampled, as evidenced by a fire lighter in a transparent bag observed next to Resident #275 while resident was seated in the activities area where other residents were gathered. There were 118 residents residing in the facility at the time of survey.

Inspectors wroteBased on observations, interviews and record review, the facility failed to demonstrate effective action plans were implemented to correct identified quality deficiencies in the problem area related to prevent repeated deficient practice for F641- Accuracy of assessment. As evidenced by inaccurate MDS coding.

Inspectors wroteBased on observations, interview and record review, the facility's staff failed to implement infection prevention control policies and procedures to ensure a sanitary environment and failed to provide proper perineal and catheter care to help prevent Urinary Tract Infections (UTI); as evidenced two clear plastic bags containing trash on the third-floor hallway and during perineal care staff did not change gloves and wash hands when transitioning from a contaminated area to a clean area and did not change water in the basin between cleaning steps. There were 116 residents residing in the facility at the time of the survey.

Inspectors wroteBased on record review and interviews, the facility failed to ensure medically needed social services were provided for one resident (Resident #4) out of three residents reviewed. The resident was charged $100.00 for someone to accompany him each time he went out to an appointment. There were 117 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the Third Floor Pantry refrigerator used exclusively for the resident's was maintained in a sanitary manner as evidenced by opened undated milk carton observed. This has the potential to affect fifty-five residents out of fifty-seven residents who eat orally residing on the Third floor.

Inspectors wroteBased on observations, interview, and record review the facility failed to provide a safe environment for residents on the second floor, as evidenced one out of one Biohazard room observed on the facility's second floor door was kept unlocked. This has the potential to affect the 58 residents residing on the second floor during the survey.

Inspectors wroteBased on observations, records review and interview, the facility failed to promote dignity while dining for two Residents (#21 and #62) out of twenty-six sampled residents, as evidenced by observations of staff standing over Resident #21 and Resident #62 while assisting to eat.

Inspectors wroteBased on record review and interview, the facility failed to electronically transmit the Discharge- Return Non-Anticipated Minimum Data Set (MDS) to Centers of Medicare and Medicaid (CMS) within 14 days for one (Resident # 10) out of two residents whose assessments were investigated. Resident #10 who was discharged to the community but the MDS was not transmitted. There were 120 residents residing in the facility at the time of survey.

Inspectors wroteBased on record reviews and interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for two (Resident #117 and Resident #44) out of four residents reviewed for residents' assessments. There were 120 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observations, records review, and interviews. The facility failed to ensure medications were securely stored, as evidenced by fourteen loose pills and two half pills were found on one out of two medication carts checked. There were 120 residents residing in the facility at the time of the survey.

Inspectors wroteBased on record review and interview the facility failed to ensure the arbitration agreements presented to three residents (Resident number 70, Resident number 84, and Resident number 220) out of three residents reviewed informed residents or their representatives of the nature and implications of any proposed binding arbitration agreement, to inform their decision on whether or not to enter into such agreements. There were 120 residents residing in the facility at the time of the survey.