Wesley Woods Health & Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for one of one kitchen reviewed for kitchen sanitation The facility failed to label, date, and seal food items in the pantry, refrigerator, and chest freezer on 3/19/2026. This failure could place residents at risk for health complications and foodborne illnesses.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide each resident with a nourishing, attractive, palatable, temperature appropriate diet that met his or her dietary needs or preferences for 5 (Resident #13, #37, #53, #58, and #79) of 13 residents reviewed for dietary services.1. The facility failed to serve food that was appetizing.2. The facility failed to ensure food was served according to expected food temperatures.3. The facility failed to serve food that was adequately cooked in that residents were served raw and/or undercooked chicken, ground meat, and potatoes These failures placed residents at risk of decreased food intake, hunger, unwanted weight loss, and diminished quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store food, serve food at the correct temperatures, and sanitize equipment correctly in accordance with professional standards for foodservice safety in the reviewed 1 of 1 kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were stored properly for 1of 2 Medication Storage rooms (Hall 300 Room) reviewed for drug storage. The facility failed to ensure expired medications were removed from the medication storage room on Hall 300 and that used dressings that were no longer sterile were also removed from the room. This failure could place residents at risk of receiving ineffective medication treatments and contaminated wound care that could result in unnecessary infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the transmission of communicable diseases and infections for 1 of 1 laundry room. The facility failed to ensure laundry staff handled and stored linens in a manner to ensure cleanliness and protect from dust and soil to prevent cross-contamination and the spread of infections. This failure could place residents at risk for development of communicable diseases and infections that could diminish a residents' quality of life.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure a resident has a right to personal privacy and confidentiality of his or her personal and medical records for 1 of 4 computers. On 08/14/2025 LVN A left the facility's computer open and unattended at the nurse's station with residents' personal medical information visible to anyone who passed by. The failure could place residents at risk of having their private information changed, viewed, and not kept secure.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to provide each resident at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care for three (Resident #1, Resident #3, and Resident #5) of 5 reviewed for timely meals. The facility failed to provide breakfast, lunch, and dinner according to the designated meal service schedules on multiple occasions. This deficient practice could place residents at risk of low blood sugar levels, increased stress levels, slowed metabolism rates, weakened immune systems, malnutrition, weakened hearts, and organ failures.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure each resident was treated with respect, dignity, and care for 1 of 5 residents (Resident #2) observed for resident rights. The facility failed to ensure Resident #2 was treated with respect and dignity when providing personal care for this resident. This failure could place residents at risk of lowered self-esteem, depression, and frustration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for three (Resident #1 and Resident #3) of five residents reviewed for pharmaceutical services. On 5/2/2025, two (2) medication cards - one from Resident #1 and one from Resident #3 - were observed with white tape on the reverse side of the card. The tape on the reverse side of the medication card indicated the potential for tampering. Administrative and nursing staff failed to be aware of patch use, failed to verify that the patches used were from the pharmacy, and failed to be trained on the use of patches to include when patches were acceptable for use in the facility policies and procedures. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and timely medication records to minimize the potential for medication related adverse consequences or events for three (Resident #1, Resident #2 and Resident #3) of five residents reviewed for med errors. A medication error occurred on 11/28/2024 where residents # 1, #2 and #3 all received a double dose of their scheduled narcotic pain medication. Residents #1, #2 and #3 received their first dose at 7pm and the second dose at 8:30 pm. The nursing facility failed to: o follow their policy for medication administration to avoid errors. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the resident had the right to be informed of, and participate in, his or her treatment including the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care and treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred for one of nine residents (Resident #1) reviewed for resident rights . The facility failed to notify Resident #1's responsible party when his labs result on 2/25/2025 indicated his lithium levels were out of range. This failure could place residents at risk of a lack of a dignified existence, self-determination and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for one (Resident #1) of six residents reviewed for resident rights. The facility failed to ensure CNA C treated Resident #1 with dignity while in his room prior to providing care on 09/25/24 as she was observed talking about non-sensical information. This failure could place residents at risk of intimidation, psychosocial harm, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for one (Resident #1) of six residents reviewed for accidents and hazards. The facility failed to ensure CNA B and CNA C appropriately utilized the mechanical lift on 9/25/24 while transferring Resident #1 to his bed causing him to hit his head on the wall. This failure could place residents at risk of harm, injury, and hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety in one of one kitchen reviewed for kitchen and food sanitation. The facility failed to ensure DA A wore a beard restraint while preparing food for residents. These failures could have placed residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the meals served reflected the nutritional needs of residents in accordance with established national guidelines for all residents when the facility failed to ensure menus were followed for all residents for 2 of 2 meals observed. The facility failed to follow the posted menus for two lunch services served at the facility on Wednesday, 09/30/24 and Thursday, 10/2/24. These failures could place residents that eat food from the kitchen at risk of poor intake, chemical imbalance, and/or weight loss.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to serve foods that were palatable and attractive and prepare food by methods that conserve nutritive value, flavor, and appearance for 1 of 1 kitchen observed. 1. The kitchen test tray of the lunch meal on 10/2/24 foods was burnt, unappealing, and inedible. The kitchen test tray lacked silverware, condiments, dessert, and a beverage. Kitchen staff had to bring missing items after test tray was received and utensils were requested. 2. The facility failed to follow the puree diet recipe. The pureed baked ham, baked sweet potatoes, and buttered peas were all mixed with water during the puree process for the lunch meal on 10/2/24 instead of something with nutritive value such as broth, milk, or juice. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to provide food that accommodates residents' allergies, intolerances, and preferences for four (4) of nine (9) residents (Residents #66, #75, #27, #77) reviewed for food preferences. The facility kitchen failed to serve menu substitution items as requested by the residents and approved by facility staff. The facility kitchen failed to make residents aware of menu substitutions available to them. This failure could affect the residents that are provided daily meals by the facility, by placing them at risk for dissatisfaction, frustration, poor intake, weight loss, and decline in health.

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 for one of one kitchen reviewed for sanitation. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR) Level I assessment accurately reflected the resident's status for 1 of 5 residents (Resident #43) reviewed for PASARR Level I screenings. 1. The facility failed to ensure the accuracy of the PASARR Level 1 screening for Resident #43. The PASARR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (bipolar disorder with an onset date of 01/24/18 and schizoaffective disorder, bipolar type with an onsite date of 02/23/24) was present upon Resident #43's admission date on 02/15/24. The facility did not complete a 1012 form to update the PASARR Level 1 with the new diagnosis until surveyor intervention on 10/02/24. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 of 6 (Resident #27, #64 and Residents # 66) residents reviewed for infection control 1) CNA #A failed to change gloves or wash her hands while performing perineal care on Resident #64 when removing a soiled brief and applying a clean brief on 10/01/24. 2) MA failed to properly sanitize blood pressure cuff when moving from one resident to another resident on 10/01/2024 when administering medications and obtaining blood pressure for Residents #27 and #66. This failure could place residents at-risk of cross contamination which could result in infections or illness.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the residents had the right to be free from abuse for one (Resident #1) out of seven reviewed for abuse. The facility failed to prevent abuse by failing to ensure Resident #1 was not pushed by CNA A resulting in a fall in his room on 5/27/2024. This failure placed residents at risk for abuse with potential for injuries, pain, trauma, and hospitalization.

Inspectors wroteBased on interviews and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one of three residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1 was assessed by RN B for injuries after his fall on 5/27/2024. This failure placed residents at risk for potential injuries, pain, and hospitalization.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food storage and labeling in that: The facility failed to ensure food and beverages were safely stored, labeled, and dated in the walk in refrigerator and freezer on 05/25/24. This deficient practice could place residents at risk of foodborne illness.

Inspectors wroteBased on interview, and record review, the facility failed to ensure to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 3 of 5 residents (Resident #1, Resident #2, and Resident #3) reviewed for medication administration, in that: LVN A failed to document the medications administered to Resident #1, Resident #2, and Resident #3, in the MAR. This deficient practice could place residents at-risk of Medication Administration Errors that leads to the danger of overdosing drugs.

Inspectors wroteBased on interview and record review, the facility failed to ensure that medical records were accurately documented for three(Resident #1, Resident #3, and Resident #7) of seven residents reviewed for accurate medical records, in that: The facility failed to ensure Residents #1, #3 and #7 had catheter care performed per physicians' orders on 1/6/24, 1/7/24, 1/8/24 and 1/12/24. This failure could place residents with indwelling urinary catheters at risk of sepsis, skin breakdown, urinary tract infections, and pain.

Inspectors wroteBased on observation, interview and record review, the facility failed to respect the residents' right for 3 (Resident #1, Resident #27, and Resident #42) of 3 residents to send and promptly receive unopened mail, letters, and packages each postal delivery day. The facility failed to ensure Residents #1, #27, and #42 had the right to receive unopened packages. The failure could affect the rights of the facility's residents by opening their packages.

Inspectors wroteBased on interview the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for all residents The facility failed to establish and implement a water management program as part of the infection control program. This failure had the potential to affect all residents in the facility by placing them at risk of contracting, spreading, and/or exposing them to bacterial or viral infections that could lead to the spread of communicable diseases.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for four of 10 residents (Resident #23, Resident #68, Resident #16, and Resident #57) reviewed for quality of life. The facility failed to ensure Resident # 23's, Resident #68's, Resident # 16's, and Resident #57's fingernails were trimmed and cleaned. These failures could place residents at risk for poor hygiene, dignity issues and decreased quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practice for 3 (Resident #20, Resident #5, and Resident #22) of 3 residents reviewed for respiratory care, in that: The facility failed to: A.) Change and date the nebulizer mask and oxygen humidifier for Resident #20 B.) Change oxygen tubing and date humidifier for Resident #5 and Resident #22 These deficient practices could place residents that receive oxygen therapy at risk for inadequate care and respiratory infection. Findings Included: Resident#20 Record review of Resident #20's face sheet dated August 2,2023 revealed the resident was an [AGE] year-old female admitted on [DATE]. [...]