Wesley Homes Des Moines Health Center

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident concerns were dealt with timely, verbal grievances were identified as such, resident rights were promoted periodically as required, and residents were provided the opportunity to make a grievance anonymously for 1 of 1 Resident Council groups reviewed. These failures placed residents at risk for unmet needs, frustration, untimely resolution of grievances, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Level 2 Pre-admission Screening and Resident Review (PASRR) determinations (a process to determine whether mental health services were required after a Level 1 PASRR screening identified the need for a Level 2 review) were obtained for 3 (Residents 3, 9, & 63) of 5 residents whose PASRRs were reviewed. This failure placed residents at risk for not receiving necessary mental health care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional standards of practice. The facility failed to: (1) label medications properly and dispose of expired medications and medical supplies timely for 1 of 2 medication carts (300 West) and 2 of 2 storage rooms (300 East and 300 West) reviewed; and (2) monitor medication refrigerator temperatures for 2 of 2 storage rooms (300 East and 300 West) reviewed. These failures placed residents at risk of receiving compromised medications with reduced or no potency, receiving care with degraded supplies, and experiencing an overall decline in quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to: ensure staff posted and followed Transmission Based Precautions (TBP - a set of infection control practices used to prevent the spread of infectious agents, in addition to standard precautions) for 1 of 4 residents (Resident 40) reviewed for TBP; ensure staff used appropriate Personal Protective Equipment (PPE - disposable barriers such as gloves, eyewear, and gowns used to prevent exposure to infectious materials) for 1 of 4 residents (Resident 44) reviewed for Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce the transmission of multidrug-resistant organisms); and ensure staff used appropriate Hand Hygiene (HH) during meal service. These failures placed residents and staff at risk for exposure to and development of communicable infectious diseases.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' medication regimens were free of chemical restraints for 1 of 5 (Resident 11) residents whose medication regimens were reviewed. This failure left residents at risk for unneeded psychotropic medications, sedation, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure comprehensive Care Plans (CPs) were developed and implemented for 5 (Residents 85, 44, 38, 10, & 9) of 20 sample residents reviewed. The failure to ensure all care needs were addressed by the CP placed residents at risk for unmet care needs, and frustration.

Inspectors wroteBased on interview and record review, the facility failed to ensure care and services were provided within professional standards of nursing for 2 (Residents 8 & 63) of 5 residents whose medication regimen was reviewed. The failure to ensure orders were clarified when needed placed residents at risk for unneeded care and unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received the assistance they were assessed to require with Activities of Daily Living (ADL) for 1 (Resident 78) of 2 residents reviewed for ADL. This failure placed residents at risk for poor hygiene, odors, skin irritation, and a diminished sense of self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate monitoring for fluid overload and edema (an abnormal buildup of fluid in bodily tissue) for 1 (Resident 38) of 2 residents reviewed for edema and failed to monitor oxygen therapy for 1 (Resident 38) of 2 residents receiving oxygen therapy. These failures to monitor for edema and to provide oxygen monitoring left residents at risk for respiratory discomfort, oxygen-related accidents, infection, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received the care and services necessary to ensure their safety for 1 (Resident 11) of 1 residents reviewed for elopement risks. The failure placed the resident at risk for elopement, lack of supervision, and accidents.

Inspectors wroteBased on interview and record review the facility failed to ensure nurse and nurse aide staff had the appropriate competencies and skill sets to provide nursing and related services, to assure resident safety, and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident according to the facility assessment, resident-specific assessments and resident plans of care for 7 of 7 staff (Staff H, I, J & K - Nurse Aids and Staff E, G, & R - Licensed Nurses) reviewed for competency. The failure to develop and implement a process to evaluate staff's competency and skills to perform job expectations, including medication pass evaluation of competency, placed residents at risk for medication errors, accidents, injuries, infections, diminished quality of life, and diminished quality of care.

Inspectors wroteBased on interview and record review, the facility failed to implement a facility-wide system for Antibiotic (ABO) Stewardship (a program to improve how ABO medications are prescribed, treating bacterial infections, and reduce the inappropriate use of ABO medications). The facility failed to implement an accurate surveillance method to track all resident infections, identify the source of infections, collect diagnostic data for organisms and ensure correct ABO treatment, identify residents' symptoms and use nationally recognized assessment criteria for prescribing ABO medications, monitor isolation precaution timelines, identifying trends in types infections or similar organisms, analyze data collected to provide ABO and infection reports to the prescribers of antibiotics. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADL), related to cleanliness and grooming for 5 (Residents 2, 3, 24, 35, & 37) of 17 sample residents reviewed for ADLs. Facility failure to provide residents who were dependent on staff for assistance with showers, shaving, and nail care, placed the residents at risk for poor hygiene, long facial hair, embarrassment, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement an infection prevention and control program to prevent, identify, report, investigate, and control infections and communicable diseases according to national standards. The failure to implement a system of surveillance designed to identify possible communicable diseases and infections before they could spread to other persons in the facility, implement Enhanced Barrier Precautions (EBP) to prevent the spread of infections for 2 of 5 residents (Residents 33 & 212), and ensure staff used Personal Protective Equipment (PPE) as required placed all residents at risk for facility-acquired or healthcare-associated infections and related complications.

Inspectors wroteBased on interview and record review, the facility failed to develop, implement and maintain an in-service training program that ensured 4 of 4 Nursing Aides (Staff H, I, J & K) completed the required training, including dementia care management and training for special needs of residents, to ensure continued competency when providing resident care. The failure to provide nurse aides the required training on hire, provide no less than 12 hours of continuing education annually, and perform annual performance evaluations to address weak areas for additional training placed residents at risk for less than competent care and services from nurse aide staff.

Inspectors wroteBased on interview and record review the facility failed to ensure informed consent (a process explaining the risks and benefits of a treatment prior to use) was obtained prior to administration of psychotropic (affecting mental state) medications for 3 of 5 residents (Resident 53, 212, & 213) reviewed for unnecessary medications. This placed residents at risk for unwanted treatment.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate and rule out abuse/neglect for 1 of 1 sampled resident (Resident 31) reviewed for abuse investigations. Facility's failure to complete a thorough investigation and provide feedback regarding the resident's concerns placed residents at risk for potential abuse and other negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure a system by which residents/representatives received required written notices at the time of transfer/discharge, or as soon as practicable for 3 of 4 residents (Residents 16, 35, & 46) reviewed for hospitalizations. Failure to ensure written notification to the resident and/or the resident's representative of the reasons for the discharge in writing and in a language and manner they understood, placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care and preferences.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) process (a federal requirement to help ensure that individuals who had a mental disorder or intellectual disabilities were offered the most appropriate setting for their needs [in the community, a nursing facility, or acute care setting]; and received the services they need in those settings), was followed for 1 of 4 residents (Resident 213) sampled for PASRR review. This failure placed residents at risk for not receiving specialized mental health services, unidentified mental health needs and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment) assessment was accurate to reflect the resident's mental health condition for 1 of 3 (Resident's 14) residents reviewed for PASRR. This failure placed residents at risk for inappropriate nursing home placement and /or not receiving timely and necessary services to meet their mental health needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement a comprehensive Care Plan (CP) for 2 of 18 sampled residents (Residents 53, 2 ) whose comprehensive CPs were reviewed. The failure to develop comprehensive, individualized CPs with resident-specific goals and/or interventions placed residents at risk for unmet care needs and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Care Plans (CPs) were accurately reviewed and revised to reflect current resident status and needs as required for 3 (Residents 24, 213, & 212) of 17 residents reviewed for CP's. This failure left residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment was free of accident hazards for 2 of 2 residents sampled for accidents (Resident 213, & 212). The failure to ensure supervision of wandering residents and safety of transfer pole device was accurately assessed for safety placed residents at risk for accidents, injury, and negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1 of 3 sampled residents (Residents 212) with urinary catheters (a flexible tube inserted into the bladder to drain urine) received care and services consistent with professional standards of care. The failure of the facility to ensure physician orders with a supporting diagnosis, routine catheter care and monitoring was provided, placed the residents at risk for infections, skin breakdown, and diminished quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 33) reviewed for pain management received the necessary treatment, services, and follow-up care to manage their pain during wound care. This failure placed residents at risk for avoidable pain, refusal of wound treatments and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff with a Nursing Assistant Registered (NAR) certificate completed a Certified Nursing Assistant (CNA) class and passed the state license exam within four months of hire for 2 of 2 NAR staff (Staff J & L) reviewed for CNA licensure. This failure placed residents at risk to receive care from unlicensed staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure 3 (Residents 3, 35, & 53) of 5 residents reviewed for unnecessary medications, were free from unnecessary psychotropic (medication that affected behavior, mood, thoughts, or perception) medications. This failure left residents at risk for unnecessary medications, adverse side effects, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5 Percent (%). Failure to properly administer 28 of 35 medications for 4 of 6 residents (Resident 54, 6, 44 and 163) observed during medication pass resulted in a medication error rate of 68 %. This failure placed residents at risk for not receiving the correct dose at the correct time or receiving less than the intended therapeutic effects of physician ordered medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dietary orders pertaining to the consistency of foods were implemented for 3 of 6 (Residents 34, 37, & 45) residents whose dietary intake was reviewed. This failure placed residents at risk for choking, poor nutritional intake, and weight loss.

Inspectors wroteBased on observation interview and record review the facility failed to store, prepare and serve food in accordance with food service safety standards. The failure to cover, label and date stored foods, maintain clean ceiling vents, and perform standard hand hygiene and glove use to prevent cross-contamination placed residents at risk of foodborne illness and diminished quality of life.

Inspectors wroteBased on observation and interview the facility failed to ensure 2 of 3 garbage dumpsters and 1 of 2 recycling dumpsters were properly covered, the surrounding areas were kept clean, and free of trash/debris and food scraps. These failures placed the facility at risk of attracting bugs, rodents, birds, and other disease-carrying germs/bacteria that could reproduce, grow, and place the residents at risk for acquiring these diseases.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was stored, prepared, and transported in a sanitary manner, and in accordance with professional standards of food safety. The failure to ensure food was stored appropriately, discarded when expired, and covered as required left residents at risk of food contamination and food-borne illness.

Inspectors wroteBased on interview and record review, the facility failed to update the Facility Assessment (FA - a required document that comprehensively assesses the levels and types of care provided, the demographic profile of the resident population, and the numbers and competencies required of the staff) to accurately reflect the resources the facility determined were necessary for day-to-day and emergency operations. This failure placed the residents at risk for not receiving needed care, services, and resources.

Inspectors wroteObservations on 08/04/2023 at 10:23 AM, showed Staff X (CNA) providing incontinence care for Resident 47 in the resident's shared bathroom. Staff X wore gloves and used a wet, soapy washcloth to assist with cleaning the resident's bottom area. After completing incontinence care, Staff X picked up a new brief and put it on the resident while wearing the same soiled gloves. Staff X continued wearing the same soiled gloves to pull up Resident 47's pants, then touched the door handle to the bathroom to open the door, locked the brakes on the resident's wheelchair, touched the handle of a walker, adjusted the footrests for the wheelchair, and then emptied the basin that was used for the soapy water prior to removing the soiled gloves. Staff X, without performing HH, was observed picking up Resident 47's toothbrush, applied toothpaste and handed it to the resident. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure there was a designated Infection Preventionist (IP) who worked at least part-time at the facility responsible for the facility's effective Infection Control and Prevention Program (IPCP) including early detection of infections, analysis of evidence-based infection surveillance data, implementation of infection prevention measures, and management of healthcare associated infections such as Antibiotic (ABO) Stewardship and Infection Surveillance including Legionella (a severe form of lung inflammation caused by a bacterial infection). These failures and the lack of leadership without a fully functional IPCP placed residents at risk for unmet care needs and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide privacy during personal care for 1 of 19 (Resident 1) residents and to cover Foley Catheter bags (FC- a tube placed in the bladder to drain urine into urinary bag), to ensure dignity for 3 of 5 (Resident 3, 1, and 59) residents. Failure to provide personal privacy placed residents at risk of feelings of institutionalization and a diminished quality of life. <Facility Policy> The facility's undated Resident Rights policy showed residents should be treated with dignity and respect and had a right to personal privacy that included their medical treatment. <Catheter Bag Privacy Cover> <Resident 3> Review of the 06/13/2023 Quarterly Minimum Data Set (MDS - an assessment tool) showed Resident 3 had a diagnosis of obstructive uropathy (obstructed urinary flow) and was admitted to the facility with a FC. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure resident rooms had access to fresh air, were clean, free of clutter, and provided a homelike environment for 2 of 3 units (200 Hall and 500 Hall). These failures left residents at risk for feelings of institutionalization, decreased quality of life, and a less than homelike environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 3 of 6 (Residents 59,12 & 33) residents reviewed for Restorative Nursing Programs (RNP) received the care and services they were assessed to require. These failures placed residents at risks for declines in Range of Motion (ROM) or functional status, and other negative health outcomes.

Inspectors wroteBased on observation and interview the facility failed to ensure the environment was free of accident hazards on 3 (100 Hall, 200 Hall & 500 Hall) of 3 units. The failure to ensure chemicals and razors were safely secured left residents at risk for accidents with a potential for injuries.

Inspectors wroteBased on interview and record review, the facility failed to put into practice protocols necessary to optimize the treatment of infections that ensured Residents 2, 42, & 7, who required the use of an antibiotic (ABO), were prescribed the appropriate ABO. The facility failed to implement a facility-wide system that monitored the use of ABOs. These failures placed residents at risk of adverse events and the development of ABO-resistant organisms from unnecessary or inappropriate ABO use.

Inspectors wroteBased on interview and record review the facility failed to ensure funds were reimbursed to the state Office of Financial Recovery (OFR), within 30 days of resident discharge or death, for 2 (Residents 317 & 316) of 4 discharged residents reviewed. This failure caused a delay in reconciling residents' accounts within 30 days as required.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were informed and provided written information concerning the right to accept, refuse, or formulate an Advanced Directive (AD - legal documents reflecting a resident's wishes if they became incapacitated) for 4 (Residents 9, 12, 7, & 10) of 19 residents reviewed for ADs. The failure to offer assistance or choose to refuse to formulate an AD placed residents at risk of not having a Power of Attorney (POA - surrogate decision maker) when unable to make their own healthcare or financial decisions.

Inspectors wroteBased on observation, interview, and record review the facility failed to notify State Survey Agency (SA) of an unwitnessed fall with injury in an area not generally vulnerable to trauma for 1 of (Resident 1) residents reviewed for falls. Failure to notify SA of unwitnessed injury put residents at risk for uninvestigated potential abuse.

Inspectors wroteBased on interview and record review, the facility failed ensure a system by which the office of the State Long-Term Care Ombudsman (LTCO) received required resident transfer information for 1 of 1 (Resident 3) residents reviewed for hospitalization. Failure to ensure required notification was completed, prevented the LTCO from educating and advocating for residents regarding their rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure baseline Care Plans (Baseline CP - individualized instructions for resident care nursing homes are required to complete for each resident within 48 hours of admission) were developed for 1 (Resident 65) of 1 residents reviewed for discharge. The failure to develop a baseline CP left the resident at risk for unmet care needs, frustration, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure comprehensive Care Plans (CPs) were developed for 2 of 19 (Residents 24 & 47) sample residents whose CPs were reviewed. These failures left residents at risk for unmet care needs and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure care planning meetings were conducted routinely and Care Plans (CP) were maintained, revised, and updated as required for 3 (Residents 47, 9, & 12) of 19 sampled residents. This failure left residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide services according to professional standards; ensure Physician's Orders (POs) were followed for 2 of 16 sample residents (Residents 47 & 7), or clarified for 1 of 16 sample residents (Resident 47), monitor the behaviors for a new diagnosis for 1 of 16 residents (Resident 9) whose care was reviewed, monitor an alteration in skin integrity for 1 of 4 (Resident 1) residents and ensure proper settings and function of air mattresses for 3 of 4 (Residents 1, 3, and 41) residents. These failures left residents at risk for not receiving the care they required, infection, accidents with potential for injuries, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Activities of Daily Living (ADLs) were provided as residents were assessed to require for 3 of 19 (Residents 33, 9 & 41) dependent residents reviewed for ADLs. Facility failure to provide bathing (Resident 33 & 9) and communication (Resident 41) assistance left residents at risk for poor hygiene, and frustration.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess for bladder needs to alert and oriented residents for a toileting program for 1 of 4 (Resident 12) residents. The facility failed to ensure residents with Foley Catheters (FC- a tube placed in the bladder to drain urine) received appropriate care and services for 1 of 5 (Resident 59) residents reviewed for indwelling FCs. The failure to assess the residents for toileting programs and obtain and follow Physician Orders (PO) for FCs care placed residents at risk for infection and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were secured, dated when opened, and expired medications and biologicals were disposed of timely for 2 of 4 medication carts, 1 of 2 medication rooms, and 1 of 64 resident rooms reviewed. This failure placed residents at risk for receiving expired medications, medication errors, adverse side effects of medications, or not receiving the full effect of their medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident dietary preferences and food allergies were honored for 2 (Residents 59 and 41) of 19 sample residents. This failure left residents at risk for frustration, allergic reactions to food, and weight loss.