Wesley Place on Honeysuckle

Inspectors wroteBased on interviews, review of Resident Identifier (RI) #195's medical records, review of a third-party complaint, and the facility's policies titled, Care Plans, Comprehensive Person-Centered and Perineal Care, the facility failed to ensure care planned interventions were developed to instruct staff how to safely position RI #195 in bed during incontinent care; including how many staff members were required to safely provide incontinent care for RI #195. The facility further failed to ensure RI #195's care planned interventions for bilateral half side rails for safety during care was implemented by Certified Nursing Assistance (CNA) #6. This deficient practice affected RI #195; one of 51 sampled residents whose care plans were reviewed. On 09/14/2023, CNA #6 was providing incontinent care to RI #195 without the assistance of another staff. [...]

Inspectors wroteBased on interviews, record review, the facility's investigative file, hospital record review, the facility policy titled, and review of a third-party complaint, the facility failed to ensure Resident Identifier (RI) #195's upper side rails were up for safety during the provision of incontinent care; and failed to ensure two staff assisted to reposition RI #195 during the incontinent care. On 09/14/2023, Certified Nursing Assistant (CNA) #6 was providing incontinent care to RI #195 without a second staff to assist. CNA #6 repositioned RI #195 to the left side, turned around to obtain a wipe, and when she turned back around RI #195 was sliding from the left side of the bed. RI #195 fell head and upper body first from the bed to the floor. According to CNA #6, the left side rail was not in the upright position at the time. [...]

Inspectors wroteBased on interviews, record review, the Long-Term Care Resident Assessment Instrument 3.0 Manual, and the facility policy titled Care Plans, Comprehensive Person-Centered, the facility failed to ensure Resident Identifier (RI) #96's Quarterly Minimum Data Set (MDS) assessment dated [DATE], was accurately coded to reflect Resident Identifier (RI) #96's behavioral symptoms. This deficient practice affected one of 51 sampled residents whose MDS was reviewed.

Inspectors wroteBased on observations, interviews, record review and review of a facility policy titled, Care Plans -Baseline, the facility failed to ensure Resident Identifier (RI) #196's and RI #198's baseline care plans addressed the use of their Continuous Positive Airway Pressure (CPAP) machines. This deficient practice affected RI #196 and RI #198, two of six sampled residents whose baseline care plans were reviewed.

Inspectors wroteBased on observations, interviews, record review and review of facility policies titled, Crushing Medications, Administering Medications, and Gastrostomy/Jejunostomy Site Care, the facility failed to ensure: 1) Resident Identifier (RI) #3 had a crush order to crush his/her Clonazepam 1 mg (milligram) tablet, and 2) RI #40's PEG (Percutaneous Gastrostomy) site was cleaned with peroxide as ordered by the physician. These deficient practices affected RI #3, one of six residents observed during the medication pass administration; and RI #40, one of one resident whose PEG site care was observed.

Inspectors wroteBased on observations, interviews, record review and review of a facility policy titled, Medication Labeling and Storage, the facility to ensure: 1) Resident Identifier (RI) #395's vial of 70/30 insulin was labeled correctly; and 2) an expired bottle of Enteric Coated (EC) Aspirin (ASA) was not left on the medication cart on the Rehab unit. These deficient practices affected RI #395, and had the potential to affect all resident with orders for EC ASA on the Rehab unit.

Inspectors wroteBased on observations, interviews, record review, review of facility policies titled, Handwashing/Hand Hygiene and Gastrostomy/Jejunostomy Site Care, and review of guidelines from CDC's (Center for Medicare and Medicare) Core Infection and Prevention and Control Practices for Safe Healthcare in All Settings, the facility failed to ensure: 1) Certified Nursing Assistant (CNA) #19 removed her mask before exiting a resident on Droplet Precautions's room, Resident Identifier (RI) #53, 2) Licensed Practical Nurse (LPN) #3 changed her gloves and sanitized her hands while performing gastrostomy site care on RI #40; and 3) Registered Nurse (RN) #4 did not use her gloved finger to pack foam into RI #295's wound during wound care. Further RN #4 used her ungloved hands and hand sanitizer to clean RI #295's. These deficient practices affected three of 51 sampled residents.

Inspectors wroteBased on observations, interviews and a facility's policy titled, Homelike Environment, the facility failed to ensure rooms on one of seven halls were not found in need of repair. This deficient practice affected eight resident's rooms on one hall. Findings Include: A facility policy titled, Homelike Environment, with a revised dated of 02/2021, revealed, Policy Statement Residents are provided with a safe, clean, comfortable and homelike environment . Policy Interpretation and Implementation . the facility staff and management maximizes, to the extent possible the characteristics of the facility that reflect a . homelike setting . These characteristics include: a. clean, sanitary and orderly environment; . 1. On 03/18/2024 at 5:35 PM the surveyor observed a large amount of wall material missing behind the Resident Identifier (RI) #70's bed. 2. [...]

Inspectors wroteI. Based on observations, interviews and a review of a facility policy titled, Serving & Storage of Food and a document titled, IN-USE UTENSILS, the facility failed to ensure: 1) Cream of wheat in the dry storage room was sealed; 2) Ham in the refrigerator was labeled and; 3) A scoop was not on laying top of the flour in the flour bin. This had the potential to affect 60 of 60 resident who received meals from the kitchen. II. Based on the facility policies titled, Food Received from the Main Kitchen and Food Preparation, the facility further failed to ensure the facility homemakers serving and plating food for meals on the units: 1. completely contained their hair in hair nets; 2. did not use the same gloves to handle food and non food items; 3. did not use hand sanitizer between glove changes while handling food; 4. did not hold an item removed from the refrigerator against her uniform; [...]

Inspectors wroteBased on observation, interview and review of a facility policy Quality of Life - Dignity the facility failed to ensure Resident Identifier (RI) #11 received the supper meal on 8/27/18 and was fed the same time the roommate was fed. This was observed on 8/27/18 and affected one of two residents observed for meals. Findings Include: A review of a facility policy Quality of Life -Dignity with a revised date of August 2009 revealed: Policy Statement Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. RI #11 was admitted to the facility 1/22/15 with a diagnosis of Dementia. A review of a Quarterly Minimal Data Set with an Assessment Reference Date of 5/31/18 revealed RI #11 was totally dependant for eating. On 8/27/18 at 5:01 PM the surveyor observed the supper meal served to the roommate who required to be fed. [...]

Inspectors wroteBased on observation, interview and review of a facility policy titled, Housekeeping, Cleaning & Laundry, the facility failed to ensure: 1) Resident Identifier(RI) #85's room was clean and free of crumbs, the carpet was not wet and the bathroom was clean and 2) the 600 Hall was free of a urine odor. This was observed on four days of the survey and affected RI #85 and the 600 Hall. Findings Include: A review of a facility policy Housekeeping, Cleaning & Laundry, no date, revealed .II. P.M. Homemaker Duty List The P.M. Homemaker will accomplish daily the following day shift cleaning duties. Clean resident rooms. 1) RI #85 was admitted to the facility 2/17/17 with a diagnosis of Urinary Tract Infection. On 8/28/18 at 10:13 AM, during a brief family interview there was concerns voiced about RI #85's room and dirty bathroom. [...]

Inspectors wroteBased on observation, interview, record review and review of a facility policy titled, Perineal Care of Incontinent Residents, the facility failed to ensure a Certified Nursing Assistant (CNA) performing incontinent care for RI # 85 did not 1. change gloves without washing her hands before applying clean gloves, and 2. did not remove a soiled pad then with same dirty gloves place a clean bed pad. This was observed on 8/29/18 and affected one of two residents observed for incontinent care. Findings Include: A review of a facility policy titled, Perineal Care of Incontinent Residents, no date, revealed .Procedure: .5. Wash your hands .11. Put on clean gloves.15 a.wash . b. rinse .20.put soiled linens in a bag. 21. Remove gloves and discard. PUT ON NEW GLOVES .22. Apply clean undergarments, diaper or underpad. [...]

Inspectors wroteBased on observation, interview and review of a facility policy Security of Medication Cart, the facility failed to ensure a licensed staff did not leave the medication cart unlocked as she walked away from it. This was observed on 8/27/18 and affected one of six nurses observed for medication pass. Findings Include: A review of a facility policy titled, Security of Medication Cart, with a revised date of April 2007 revealed, Policy Statement The medication cart shall be secured during medication passes. Policy Interpretation and Implementation .4. Medication carts must be securely locked at all times when out of the nurse's view. On 8/27/18 at 4:00 PM, the surveyor observed Employee Identifier (EI) #2, Licensed Practical Nurse passing medication. EI #2 was in the medication cart then left the cart and went to a resident's room. EI #2 did not lock the medication cart. [...]

Inspectors wroteBased on observation, interview and review of a facility policy titled, Perineal Care of Incontinent Residents, the facility failed to ensure a Certified Nursing Assistant(CNA) did not place a soiled brief on the floor and did not touch a clean brief and clean clothing with the same soiled gloves she had on during the provision of incontinent care for Resident Identifier (RI) #10. This was observed on 8/28/18 and affected one of two residents observed for incontinent care. Findings Include: A review of a facility policy Perineal Care of Incontinent Residents revealed: .Procedure: .11. Put on clean gloves. 20.put soiled linens in a plastic bag. 21. Remove gloves and discard. PUT ON NEW GLOVES before continuing with care. 22. Apply clean undergarments, diaper or underpad. RI #10 was admitted to the facility on [DATE] with a diagnosis of Vascular Dementia. [...]

Inspectors wroteBased on observation, interview and a review of a facility policy titled Food -Related Garbage and Rubbish Disposal, the facility failed to ensure the dumpster door on the dumpster was closed. Findings Include: A review of a facility policy titled Food-Related Garbage and Rubbish Disposal, with a revised date of April 2006 revealed, .Policy Interpretation and Implementation . 7. Outside dumpster provided by garbage pick up services will be kept closed and free of surrounding litter . On 8/27/18 at 4:07 p.m., the surveyor along with EI #14, the cook observed the dumpster door opened at the side. On 8/30/18 at 10:25 a.m., the surveyor conducted an interview with EI #14. EI #14 was asked what did she observe regarding the dumpster door on 8/27/18. EI #14 replied, the door on the rear was left opened. EI #14 was asked who was responsible for making sure the dumpster doors were closed. [...]