W Frank Wells Nursing Home

Inspectors wroteBased on the kitchen food service observations, staff interviews, facility document review and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness with the potential to affect all of the residents in the facility. The facility failed to ensure that the dietary staff used proper procedures for hand hygiene, disposable glove use, food storage and proper sanitation practices in the kitchen and for the two ice machines located in the main dining room and the restorative dining area. Safe food handling and good sanitation is important in health care settings serving nursing home residents due to the risk of serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices represent a potential source of pathogen exposure.

Inspectors wroteBased on facility document review, staff interview and facility policy and procedure review the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) committee composed of required members when the Medical Director failed to attend QAPI meetings on a monthly or quarterly basis from July 2024 through November 2024. The facility failed to provide evidence of communication of the program data to the Medical Director for his review and receive meaningful feedback from him on possible quality deficiencies and trends that might have required more frequent monitoring and may have resulted in negative health outcomes for the residents of the facility.

Inspectors wroteBased on observations and interviews, the facility failed to address missing wall trim mid-wall, leaving sharp and splintered wood exposed in three (rooms [ROOM NUMBER]) of 16 rooms observed on the east hall, from a total of 36 rooms in the facility. Sharp and splintered wood in resident rooms could result in resident injury with pain and possible infection.

Inspectors wroteBased on observations, interviews, record review, and facility policy and procedure review, the facility failed to provide oxygen at the prescribed flow rate for one (Resident #7) of one resident reviewed for oxygen therapy from a total survey sample of 23 residents.

Inspectors wroteBased on observations, interviews, record review, and facility policy and procedure review, the facility failed to honor food preferences for one (Resident #2) of one resident reviewed for food preferences from a total survey sample of 23 residents.

Inspectors wroteBased on observations, staff interviews, resident, facility, and staff record reviews, the facility's policy Resident Elopement, the Facility Assessment, and the Administrator's job description, the facility administration failed to provide sufficient oversight, identify needed resources and ensure staff were sufficiently equipped to provide adequate supervision and implement relevant measures to prevent elopement (leaving the premises without supervision or staff knowledge) and minimize the risk of injury or death for Resident #1 and all seven of the other residents identified as at risk for elopement. The facility failed to have a systematic process in place to educate staff, identify environmental risks, revise plans of care, and develop, and implement relevant interventions to protect residents from exiting the facility without staff knowledge or supervision. [...]

Inspectors wroteBased on observations, staff interviews, resident, facility, and staff record reviews, the facility's policy for Resident Elopement, the Facility Assessment, and a review of the Quality Assurance and Performance Improvement (QAPI) Program, the facility failed to have an effective Quality Assurance and Performance Improvement (QAPI) process to monitor/audit facility practices involving resident elopements, assessment of elopements, staff education and competencies, and development of effective safety and preventative measures for Resident #1, who was identified as an elopement risk, as well as seven other residents identified as at risk for elopement. [...]

Inspectors wroteBased on observations, staff interviews, resident, facility, and staff record reviews, and the facility's policy for Abuse Prevention/Reporting, the facility failed to protect the resident's right to be free from neglect. The facility failed to have a systematic process in place to protect Resident #1 and all residents identified as at risk, from harm or possible death. The facility failed to identify environmental risks, revise the plan of care, and develop and implement necessary and relevant interventions to protect vulnerable residents from exiting the facility without staff knowledge and supervision. This created a likelihood that Resident #1, or any other vulnerable at-risk resident, could leave the facility undetected and suffer serious physical harm. The facility census was 57 residents on 6/12/24; [...]

Inspectors wroteBased on observations, staff interviews, resident, facility, and staff record reviews, and the facility's policy for Resident Elopement, the facility failed to provide supervision and implement sufficient interventions to maintain resident safety, prevent elopement (leaving the premises without supervision or staff knowledge) and minimize the risk of injury or death for Resident #1 and all residents identified as at risk for elopement. The facility failed to have a systematic process in place to educate staff, identify environmental risks, revise plans of care, and develop, and implement relevant interventions to protect vulnerable residents from exiting the facility without staff knowledge and supervision. The resident census was 57 on 6/12/24, eight of whom had been identified as at risk for elopement and fitted with a wander monitoring device. [...]

Inspectors wroteBased on a review of the facility's policy and staff interview, the facility failed to maintain documentation to demonstrate evidence of its ongoing Quality Assurance Performance Improvement (QAPI) program.

Inspectors wroteBased on policy review and staff interviews, the facility failed to effectively maintain a system to identify, collect and use data and information from all departments, including, but not limited to the facility assessment, adverse event monitoring, and feedback from direct care staff, including how such information would be used to develop and monitor performance indicators.

Inspectors wroteBased on record review and interview, the facility failed to obtain physician's orders and a diagnosis for a urinary catheter for one (Resident #12) of two residents sampled for a review of urinary catheters, from a total of 19 residents in the sample.

Inspectors wroteBased on observations, policy review, and staff interview, the facility failed to follow appropriate infection control guidelines for urinary catheter bags for two (Residents #2 and #12) of seven residents with urinary catheters, from a total of 19 residents sampled.