Wesley Court Health Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident received food that is palatable, attractive, and at a safe and appetizing temperature for 1 of 1 lunch meal tested for nutritive value, flavor, and appearance:The facility failed to provide palatable food served at an appetizing temperature and appetizing texture to residents on 07/07/2025. This failure could affect the residents by placing them at risk of poor food intake and/or dissatisfaction of the meals served.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure that staff utilized proper personal hygiene practices while handling food. These failures could place residents that eat out of the kitchen at risk for food borne illnesses.

Inspectors wroteBased on record review and interviews, the facility failed to ensure completion of a discharge summary including a recapitulation of the resident's stay, and final status at discharge for 2 of 5 (Resident #6 and Resident #29) residents reviewed for discharge summary. The facility failed to complete a discharge summary for Resident #6 and Resident #29. This failure could place residents at risk of not having complete records after permanent discharge from the facility and disruption in the continuity of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care for 1 of 16 (Resident #82) residents reviewed for care plan completion. The facility failed to include Resident #82's colostomy and diagnosis of Diabetes Meletus in the baseline care plan within the required 48-hour timeframe. This failure could place residents who were newly admitted at risk for not receiving necessary care and services or having important care needs identified.

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for 1 (Resident #12) of 14 residents reviewed for hospice services. The facility failed to maintain the required hospice forms and documentation, that included certificate of terminal illness and hospice election form, to ensure that the needs of the resident were addressed and met 24 hours per day to ensure Resident #12 received adequate end-of-life care. [...]

Inspectors wroteBased on interviews and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care of 4 (Resident #85, Resident #87, Resident #137, and Resident #185) of 4 residents reviewed for baseline care plan completion. The facility failed to complete the social services section in the baseline care plan for Resident #85, Resident #87, Resident #137, and Resident #185 within the required 48-hour timeframe. This failure could place residents who were newly admitted at risk for not receiving necessary care and services or having important care needs identified.

Inspectors wroteBased on interviews and record review, the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were addressed for 1 of 5 residents (Resident #28) reviewed for unnecessary medications, psychotropic medications, and medication regimen review. The facility failed to address the Pharmacist Consultant recommendations for April 2024 and May 2024 for Resident #28 regarding psychotropic medications. These failures could place residents on psychotropic medications at risk for possible adverse side effects, adverse consequences, and decreased quality of life.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure residents with PRN orders for psychotropic drugs were limited to 14 days for 1 (Resident #28) of 5 residents reviewed for pharmacy services. The facility failed to ensure Resident #28 had stop dates for PRN hydroxyzine (medicine used to treat the symptoms of anxiety). This failure could place residents at risk for psychotropic medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications.

Inspectors wroteBased on interviews and record review, the facility failed to maintain an ongoing Quality Assurance & Performance Improvement (QAPI) committee that included at minimum, the director of nursing services, the Medical Director or his/her designee, and at least three other members of the facility's staff, at least one of who must be the Administrator, owner, a board member, or other individual in a leadership role; and meets at least quarterly for 2 of 4 quarterly meetings (July 2023 & January 2024). The facility failed to ensure they held QAA quarterly meetings and had documentation that the required members were present in the meetings between April 27, 2023, to October 5, 2023, and between October 5, 2023, to March 28, 2024. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure 2 of 8 (CNA-B and CNA-C) employees whose in-service records were reviewed had not received the required minimum 1-hour annual in-service training for Dementia. The facility failed to provide the required annual Dementia training to CNA-B, and CNA-C. This failure placed residents at risk for unmet needs due to untrained staff.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure stored foods were properly labeled and dated. 2. The facility failed to ensure that equipment and utensils were stored in a manner to prevent contamination from dust and debris. These failures could affect residents who received meals prepared meals from the kitchen at risk for food borne illness and cross-contamination.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care of the resident that met professional standards of care within 48 hours of the resident's admission for 7 of 9 residents (Residents #16, #21, #186, #188, #189, #193, and #194) reviewed for baseline care plans. The facility failed to complete baseline care plans for Residents within 48 hours of admission that included the minimum required healthcare information including ADL needs, therapy, specialized medication monitoring, fall risk, and pain relief interventions for Residents #16, Resident #21, Resident #186, Resident #188, Resident #189, Resident #193, and Resident #194. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 6 of 9 residents (Residents #6, #16, #21, #186, #188, #189) reviewed for care plans in that: Resident #6 did not have care plans in place for insulin use or hypertensive monitoring. Resident #16 did not have care plans in place for delirium, cognitive loss/dementia, ADL status (including urinary incontinence), psychosocial well-being, falls, dehydration status, weight loss, or pressure injury. Resident #21 did not have care plans in place for her insulin use or constipation. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection control program designed to prevent the development and transmission of infections for 1 of 3 residents (Resident #139) reviewed for infection control. 1. LVN A failed to perform hand hygiene appropriately prior to providing wound care for Resident #139. 2. LVN A used dirty scissors to cut Vaseline gauze that was applied to wound for Resident #139. These failures could place residents at risk for transmission of diseases and organisms.

Inspectors wroteBased on interview, and record review, the facility failed to ensure an acceptable parameter of nutritional status was maintained for 1 of 3 residents (Resident #16) who was reviewed for nutritional status, in that: Resident #16 had a significant weight loss of 22.5 pounds, (13% loss 30 days). The facility did not provide any nutritional interventions for two weeks even though Resident #16 had a known history of weight loss. This failure could place residents at risk for further weight loss and decline in health due to nutritional needs not being met.