Wesley Village

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of foodborne illness in the food and nutrition services department.

Inspectors wroteBased on a review of clinical records, grievances filed with the facility, and resident and staff interviews, it was determined the facility failed to ensure residents are afforded the opportunity to make informed treatment decisions and choose preferred alternatives for one out of four residents sampled for a closed record review (Resident 128).

Inspectors wroteBased on clinical record and select policy review, staff and resident interviews, it was determined the facility failed to timely assess and implement interventions to address one of 25 residents' pain (Resident 2).

Inspectors wroteBased on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to ensure that a resident's drug regimen was free of unnecessary antibiotics for one out of 25 residents sampled (Resident 83).

Inspectors wroteBased on observations, review of clinical records, resident and staff interviews, and meal test tray results, it was determined the facility failed to serve meals that were palatable and at safe and appetizing temperatures for a test tray completed on the [NAME] Unit during the breakfast meal and for experiences of five of 25 residents sampled (Residents 82, 83, 20, 44, and 105).

Inspectors wroteBased on observation and resident and staff interviews, it was determined the facility failed to post the most recent survey results which include any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility and experiences reported by 5 out of 5 residents interviewed during a group interview (Residents 8, 44, 51, 55, and 105).

Inspectors wroteBased on clinical record review, review of select facility policy, and staff interview, it was determined the facility failed to provide quality care as evidenced by the facility failure to ensure physician orders were followed for the administration of medication for one resident (Resident 61) and further failed to develop procedures and criteria for a palliative care program (Specialized medical care for people with serious illness. This type of care is focused on providing relief from the symptoms and stress of a serious illness. The goal is to improve quality of life for both the patient and the family.) to provide person-centered care in accordance with the comprehensive person-centered care plan, and the residents' choices for palliative care for two of 28 sampled residents (Residents 14 and 39).

Inspectors wroteBased on clinical record review, select facility policy, and staff interviews, it was determined the facility failed to ensure that residents or their representatives were informed of treatment options, as well as the risks and benefits for psychotropic medications for one of 28 residents (Resident 24).

Inspectors wroteBased on a review of select facility policy, clinical records, and staff interviews, it was determined the facility failed to ensure physician orders were consistent with a resident's documented code status (hospital designation that means to intercede if a patient's heart stops beating or if the patient stops breathing) preference for one of 28 residents reviewed (Resident 75).

Inspectors wroteBased on a review of clinical records, select facility policy, observation, and resident and staff interviews, it was determined the facility failed to ensure oxygen therapy was administered per physician's orders for one resident out of 28 sampled (Resident 43).

Inspectors wroteBased on clinical record review, select facility policy review, and staff interview, it was determined the facility failed to reassess a resident's pain status and medication prescribed on as-needed (PRN) basis to ensure the development and implementation of an effective, individualized pain management plan for one of 28 residents sampled. (Resident 14).

Inspectors wroteBased on a review of clinical records, observation, and staff interview it was determined the facility failed to provide a physician ordered therapeutic diet (diet ordered by a physician or other delegated provider that is part of tthe treatment for a disease or clinical condition, to eliminate, decrease, or increase certain substances in the diet, or to provide mechanically altered food when indicated) for one resident out of 28 sampled (Resident 54).

Inspectors wroteBased on review of clinical records, facility-initiated transfer notices, and staff interview, it was determined the facility failed to provide copies of written notice of facility-initiated hospital transfers of residents to a representative of the Office of the State Ombudsman for five out of 28 residents reviewed (Residents 1, 20, 87, 90, and 18).

Inspectors wroteBased on review of the facility's admission agreement and staff interview, it was determined that the facility failed to ensure a neutral and fair arbitration process by ensuring both the resident and resident representative, and the facility agree on the selection of a venue that is convenient to both parties.

Inspectors wroteBased on observations, a review of clinical records, select facility policy, resident incident/accident report and staff interviews, it was determined that the facility failed to provide adequate staff supervision and effective safety measures to prevent elopement for two residents (Resident CR1 and Resident 2) out of 4 residents reviewed, The facility further failed to identify staff's reliance on the facility's alarm system to prevent elopements and the deficiencies of this system to prevent future unsupervised exits from the facility, which placed residents in immediate jeopardy of future unsupervised exits from the facility and the potential for serious bodily injury or death.

Inspectors wroteBased on review of clinical records, select resident incident report, and staff interviews it was determined that the facility failed to provide nursing services consistent with professional standards of quality by failing to thoroughly conduct and document the results of a professional nursing assessment regarding the clinical status of a resident following an elopement from the facility for one resident (Resident CR1) out of 4 residents reviewed.

Inspectors wroteBased on a review of observations, clinical records, investigate reports, staff interviews, and employee job descriptions it was determined the facility's administration failed to effectively use its resources to promote resident safety by failing to implement established procedures to monitor resident whereabouts and prevent an elopement for one out of 4 sampled residents (Resident CR 1).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of opioid pain medications prescribed on an as needed basis for one resident out of 24 residents reviewed (Resident 10).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to attempt a gradual dose reduction of psychoactive medications for one resident (Resident 44) and failed to clinically justify the increase of psychoactive medication for one resident (Resident 69) out of five sampled.

Inspectors wroteBased on observation, a review of select facility policy, and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department and two of three resident pantries.

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to timely consult with the physician regarding a significant weight gain displayed by one resident out of 24 sampled (Resident 12).

Inspectors wroteBased on observation, clinical record review and staff interview, it was determined that the facility failed to maintain a clean and sanitary environment for one resident out of 24 sampled (Resident 111).

Inspectors wroteBased on observation, clinical record review and staff interview, it was determined that the facility failed to timely develop and implement a person-centered care plan to meet one resident's current needs for the use of an implantable cardiac recording devices out of 24 sampled residents (Resident 69). Findings including: Clinical record review revealed that Resident 69 was admitted to the facility on [DATE], with diagnoses anxiety, seizures, and stroke. Documentation in the clinical record revealed that on October 1, 2023, Resident 69 had an implantable loop recorder (a small device placed just under the skin of the chest during a minor surgery which records the heartbeat continuously for up to three years. Device requires a transmitter at bedside to automatically send information from recorder to the health care provider). [...]

Inspectors wroteBased on observations, clinical record review and staff interviews, it was determined that the facility failed to ensure each resident timely received the necessary behavioral health care to attain or maintain the highest practicable mental and psychosocial well-being for one of 24 residents sampled (Resident 53).

Inspectors wroteBased on review of clinical records and controlled drug records, and staff interview, it was determined that the facility failed to implement procedures to promote accurate accounting of controlled medications for one of 24 residents sampled (Resident 10).

Inspectors wroteBased on a review of clinical records and staff interviews it was determined that the facility failed to ensure that the resident's drug regimen was free of unnecessary antibiotic drugs for one out of 24 residents sampled (Residents 19).

Inspectors wroteBased on review of clinical records and transfer notices, and staff interviews, it was determined that the facility failed to provide written notices of facility-initiated transfers to the resident and the resident's representative for one out of the 24 residents reviewed (Residents 69).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to provide prescribed treatment necessary to manage constipation and promote normal bowel activity to prevent related complications and demonstrate timely and thorough assessment of a resident for one resident out of seven sampled (Resident 1).