Wesleyan Village

Inspectors wroteBased on observations, resident and staff interviews, record reviews for nursing staff schedules, timecards, facility assessment, and Payroll Based Journal, the facility failed to maintain sufficient staffing levels to ensure residents received timely care and services. This affected Residents #3, #13, #24, #37, #62, #64, and #73 and had the potential to affect all 79 residents residing in the facility.

Inspectors wroteBased on observations, policy review, and staff interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect 76 of 79 residents who received food from the kitchen. Three residents (Residents #8, #28, and #57) received enteral nutrition and did not receive meals from the kitchen.

Inspectors wroteBased on observation, staff interviews, and policy review, the facility failed to ensure all narcotic count sheets were signed, completed, and maintained to ensure the disposition of all controlled drugs included accurate receiving, dispensing, and reconciliation of all controlled substance medications at every shift change. This had the potential to affect 31 residents who received controlled substances at the facility. The facility census was 79.

Inspectors wroteBased on observations and resident and staff interviews, the facility failed to serve food to the residents at palatable temperatures. This affected nine residents (#9, #12, #13, #34, #38, #53, #73, #77, and #81) and had the potential to affect the residents who receive meal trays in their room. The facility census was 79.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to maintain resident rooms, handrails, and hallways in a safe, clean and orderly manner. This affected 13 residents (#1, #13, #15, #20 #21, #32, #33, #34, #53, #63, #70, #72, and #80) with the potential to affect all 50 residents of the second and third floor. The facility census was 79.

Inspectors wroteBased on observations, record review, resident and staff interviews, and policy review, the facility failed to ensure call lights were within reach of residents. This affected two (Residents #10 and #34) of 40 residents reviewed in the initial pool sample. The facility census was 79.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure accurate advanced directive information was present throughout the residents' medical record. This affected one (Resident #1) of one resident reviewed for advanced directives. The facility census was 79.

Inspectors wroteBased on observations, resident and staff interviews, and medical record review, the facility failed to ensure residents who were dependent on staff with their activities of daily living (ADL) received timely and routine assistance with incontinence care and bathing and adequate nail care. This affected three (Resident #13, #64, and #70) of three residents for ADL care. The facility census was 79.

Inspectors wroteBased on medical record review, staff interviews, and policy review, the facility failed to ensure nutrition recommendations were timely implemented for a resident triggering for a significant weight loss who relied solely on enteral nutrition for their nutritional needs. This affected one (Residents #8) of four residents reviewed for nutrition. The facility census was 79.

Inspectors wroteBased on staff interviews, policy review, and record review, the facility failed to ensure Resident #7 was assessed before and after dialysis. This affected one (#7) of one resident reviewed for dialysis. The facility identified one resident (#7) who was on dialysis. The facility census was 79.

Inspectors wroteBased on observation, staff interview, record review, review of Centers for Disease Control and Prevention (CDC) guidance, and policy review, the facility failed to ensure staff implemented enhanced barrier precautions when providing high contract resident care activities. This affected one (Resident #34) of five residents reviewed for infection control. The facility census was 79.

Inspectors wroteBased on medical record review, observation, resident interview, and staff interview, the facility failed to provide a clean and homelike environment. This affected one resident (#11) of six residents reviewed for environment. The facility census was 89.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to assist residents in obtaining routine dental care. This affected one resident (#68) of two residents reviewed for dental care. The facility census was 89.

Inspectors wroteBased on record review, observation, resident interview, and staff interview, the facility failed to ensure Resident #68 timely received an evaluation by therapy services for a motorized wheelchair. This affected one (Resident #68) of five residents reviewed for rehabilitation services. The facility census was 89.

Inspectors wroteBased on medical record review, resident and staff interview, and review of the facility policy, the facility failed to have sufficient staffing to meet the care needs of all residents. This directly affected three (#4, #15, and #16) of five residents reviewed for staffing and had the potential to affect 18 (#5, #8, #12, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, and #45) additional residents residing on the fourth floor. The facility census was 84.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure resident weights were obtained and monitored in accordance with physician orders, dietitian recommendations, and the plan of care. This affected two (#4 and #15) of three residents reviewed for weights. The facility census was 84. 1. Review of the medical record revealed Resident #4 was initially admitted to the facility on [DATE]. The resident discharged to the hospital on [DATE] and re-admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, muscle weakness, need for assistance with personal care, hypertension, chronic kidney disease, anxiety, and depression. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 was cognitively intact. [...]

Inspectors wroteBased on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to administer medications in accordance with physician orders. This affected two (#6 and #16) of four residents reviewed for medication administration.

Inspectors wroteBased on medical record review and staff interview, the facility failed to adequately monitor resident blood glucose levels for sliding scale insulin as ordered. This affected one (#4) of three residents reviewed for insulin administration. The facility census was 84.

Inspectors wroteBased on medical record review, resident and staff interview, and review of the facility policy, the facility failed to ensure residents were free from significant medication errors. This affected one (#16) of four residents reviewed for medication administration. The facility census was 84.

Inspectors wroteBased on medical record review, review of shower schedules, and staff interview, the facility failed to ensure residents were provided adequate bathing as scheduled. This affected three (#212, #277, and #300) of three residents reviewed for activities of daily living. The facility census was 82.

Inspectors wroteBased on observation, medical record review, staff interview, and review of a facility investigation, the facility failed to ensure a resident assessed and care planned for elopement was provided with adequate supervision to prevent elopement. This affected one (#212) out of three residents reviewed for elopements. The facility census was 82.

Inspectors wroteBased on observation, review of medical records, review of facility self-reported incidents (SRI), interviews with staff, interview with family, interview with the Wound Care Certified Nurse Practitioner (WCCNP), interview with the Medical Director (MD), review of timecard punches and review of the facility policy, the facility failed to ensure residents were free from staff-to-resident physical and verbal abuse. This resulted in Immediate Jeopardy and the potential for serious injuries, negative health outcomes, and/or psychosocial harm when on 05/19/24 at approximately 5:30 P.M., the facility failed to recognize and appropriately respond to an allegation of staff-to-resident abuse when Registered Nurse (RN) #500 was witnessed by State Tested Nursing Assistant (STNA) #465 and STNA #501 swearing and yelling at Resident #19. [...]

Inspectors wroteBased on medical record review, review of self-reported incidents (SRI), interviews with staff, interview with the Medical Director (MD), interview with the Wound Care Nurse Practitioner (WCCNP), review of staff schedules, review of the facility investigation and review of the facility policy, the facility failed to ensure an allegation of staff-to-resident abuse was accurately reported and thoroughly investigated to protect residents from further potential abuse. This resulted in Immediate Jeopardy and the potential for serious injuries, negative health outcomes, and/or psychosocial harm when on 05/19/24 at approximately 10:21 P.M. the Administrator filed an SRI for an injury of unknown origin after State Tested Nursing Assistant (STNA) #465 and STNA #501 alleged verbal and physical abuse of Resident #19 by Registered Nurse (RN) #500. [...]

Inspectors wroteBased on observation, review of medical records, interviews with staff, review of hospital records, review of the Certificate of Death, review of the National Pressure Injury Advisory Panel (NPIAP) and review of the facility policy, the facility failed to provide necessary care and services to prevent and subsequently promote healing and/or worsening of a facility acquired pressure ulcer. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or death, when the facility failed to implement interventions to prevent the development of a facility acquired pressure ulcer, such as turning and repositioning and incontinence care for Resident #91, who was at risk for pressure ulcer development. [...]

Inspectors wroteBased on closed medical record review, hospital record review, staff interviews, and review of facility policy, the facility failed to ensure physician ordered treatments were provided to promote healing of a surgical wound. Actual Harm occurred when Resident #90's surgical wound was not assessed until five days after admission and had 60% slough over then wound, physician ordered treatments were not administered as ordered leading to infection of the surgical wound, requiring a seven-day hospitalization, treatment with intravenous antibiotics, and the placement of a wound vacuum for healing. Upon readmission to the facility, the facility failed to initiate the physician order for a wound vacuum for the surgical wound site for three days and then failed to apply and change as ordered. This affected one (#90) of four residents reviewed for wounds. The facility census was 86.

Inspectors wroteBased on observation, medical record review, staff interviews, and review of facility policy, the facility failed to ensure residents received timely incontinence care. This resulted in actual psychosocial harm when one resident (#40) was observed sitting in her wheelchair in her room. Resident #40 had a foul odor of urine and stool on her body, as well as her room. A blanket placed on the floor under Resident #40's wheelchair was saturated with urine, which was dripping onto the floor. Additionally, Resident #40 was wearing an adult brief and pull-up, both saturated in urine, as was a bed pad and blanket placed on the wheelchair seat under Resident #40. Resident #40 cried regarding the lack of incontinence care and stated it made her feel horrible. [...]

Inspectors wroteBased on observation, resident interview, staff interview, medical record review and review of the facility assessment to provide competent support and care for the resident population, the facility failed to ensure sufficient staff to meet the individualized needs of each specific resident. This affected three (#62, #40 and #34) of three residents reviewed for staffing. Additionally, the remaining 83 residents residing in the facility were placed at potential risk for not having their individualized needs met based on insufficient staffing resources necessary to provide competent support and care for the resident population. The facility census was 86.

Inspectors wroteBased on observation, resident interview, staff interview and review of the facility assessment, the facility failed to accurately assess and identify the needed competent nursing staff resources, based on resident acuity, to meet the individualized needs of specific residents. This affected three (#62, #40 and #34) of three residents reviewed for staffing with the potential to affect the remaining 83 residents residing in the facility who required nursing staff to meet their care needs. The facility census was 86.

Inspectors wroteBased on observation, medical record review, resident interview and staff interview, the facility failed to ensure resident rooms were adequately maintained. This affected one (#67) of three residents reviewed for safe and homelike environment. Additionally, the facility failed to ensure common areas, accessible to residents, was free from mold. This had the potential to affect three (#49, #75 and #86) of three male residents identified by the facility as being independent with mobility and toileting. The facility census was 86.

Inspectors wroteBased on observation, medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to provide routine dressing changes to a central line for one (#62) of one resident reviewed for the care and treatment of a central line. The facility identified one resident with a central line. The facility census was 86.

Inspectors wroteBased on staff interview, record review, policy review, review of the Ohio Department of Health's Certification and Licensure System website, and review of a local police report, the facility failed to ensure an incident of alleged resident-to-resident physical abuse between Resident #99 and Resident #101 was reported. This affected two (Residents #99 and #101) of three residents reviewed for abuse. The facility census was 90.

Inspectors wroteBased on staff interview, record review, policy review, review of the Ohio Department of Health's Certification and Licensure System website, and review of a local police report, the facility failed to ensure an incident of alleged resident-to-resident physical abuse between Resident #99 and Resident #101 was investigated. This affected two (Residents #99 and #101) of three residents reviewed for abuse. The facility census was 90.

Inspectors wroteBased on staff and resident interview, record review, and policy review, the facility failed to ensure resident showers were completed as planned. This affected three (Residents #05, #44, and #56) of three residents reviewed for activities of daily living. The facility census was 90.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility failed to ensure Resident #48 was served her physician-ordered diet which accommodated her dietary restrictions. This affected one (Resident #48) of three residents reviewed for dietary services. The facility census was 90.

Inspectors wroteBased on record review, staff interviews, and policy review, the facility failed to ensure colostomy care and services were in place for Resident #99. This affected one (Resident #99) of three residents reviewed for changes in condition. The facility identified no current residents with a colostomy and/or ileostomy. The facility census was 86.

Inspectors wroteBased on record review, observations and staff interviews and resident interviews the facility to ensure there was enough staff was available to meet resident needs timely. This affected three (Resident #27, #39 and #87) of five residents reviewed for staffing This had the potential to affect all 90 residents residing in the facility.

Inspectors wroteBased on medical record review, observation, and resident and staff interviews, the facility failed to ensure a resident was treated with respect when her call light was not answered for greater than one hour. This affected one (Resident #27) of five residents reviewed for call lights. The facility census was 90.

Inspectors wroteBased on medical record review, observations, and staff and resident interviews, the facility failed to ensure incontinence care was provided to the residents in a timely manner. This affected two (Resident #39 and #87) of three residents reviewed for incontinence care. The facility census was 90.

Inspectors wroteBased on medical record review, interviews with facility staff, review of an incident report, review of the emergency medical technician (EMT) report, review of the hospital computed tomography scan (CT), review of the hospital emergency room (ER) documentation, and review of the facility policy titled Falls and Fall Risk, Managing, the facility failed to provide adequate supervision and ensure care planned interventions to prevent falls were consistently implemented for one resident (#86) to prevent a fall with injury in the facility. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure staff cleaned the food thermometer appropriately to prevent cross contamination or food borne illness. This had the potential to affect 19 (Residents #2, #6, #12, #14, #17, #19, #20, #32, #41, #45, #50, #52, #56, #60, #63, #69, #73, #78 and #79) residents residing on the fourth floor of the facility. The facility census was 85.

Inspectors wroteBased on observations, record review, review of the facility's policy, and staff interview the facility failed to maintain a clean and sanitary kitchen and dietary areas. This had the potential to affect all residents except one resident (#35) who received nothing by mouth. The facility census was 92.

Inspectors wroteBased on observation, medical record review, facility policy review, and resident and staff interviews, the facility failed to ensure the licensed nurses observed the residents consumed their medications. This affected two (Resident #63 and #74) of 22 residents observed in the initial pool sample and had the potential to affect the 20 residents (Resident #4, #5, #6, #7, #14, #22, #28, #29, #34, #44, #52, #53, #66, #72, #74, #77, #79, #80, #85, and #488) whom resided on the dementia care unit on the second floor. The facility census was 92.

Inspectors wroteBased on medical record review and resident and staff interviews, the facility failed to ensure residents had a choice in their medication schedule and activities to attend. This affected two (Residents #42 and #63) of 22 residents regarding choices in their care and treatment. The facility census was 92.

Inspectors wroteBased on record review and staff interview, the facility failed to notify the appropriate state agency (The Ohio Department of Mental Health) of a significant change in a resident's mental health condition as required. This affected one (Resident #71) of two residents reviewed for preadmission screening and resident review (PASARR). The facility census was 92. Findings Include: Review of Resident #71's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included depression, chronic obstructive pulmonary disease, and hypertension. The resident was later diagnosed with unspecified psychosis while residing in the facility on 10/15/21. Review of the psychiatric consult note for Resident #71 dated 11/04/21 revealed Resident #71 was very paranoid, agitated, and irritable with exhibited anger outbursts, yelling, and physical aggression. [...]

Inspectors wroteBased on observations, medical record review, review of the facility's policy, and resident and staff interview, the facility failed to ensure residents whom were dependent on staff with activities of daily living (ADL) care were assisted with nail care. This affected two (Resident #35 and #38) of two residents reviewed for ADLs. The facility identified 81 residents who required assistance from staff with hygiene. The facility census was 92.

Inspectors wroteBased on medical record review and resident and staff interviews, the facility failed to ensure physician's orders were timely implemented for a resident. This affected one (Resident #35) of 22 residents reviewed for physician orders. The facility census was 92.

Inspectors wroteBased on observations, medical record review, and family and staff interviews, the facility failed to ensure fall interventions were in place for a resident. This affected one (Resident #33) of two residents reviewed for falls. The facility census was 92.

Inspectors wroteBased on observations, medical record review, review of the facility's dietitian recommendation protocol, and staff interviews, the facility failed to timely implement a registered dietitian's (RD) recommendation to increase a rate in tube feeding to increase the caloric intake of a resident. This affected one (Resident #35) of three residents reviewed for nutrition. The facility identified one resident with a feeding tube. The facility census was 92.

Inspectors wroteBased on medical record review, review of medscape.com guidance and staff interviews, the facility failed to ensure a resident's blood pressure medications were not administered close together. This medication has the potential to significantly drop blood pressure and was a significant medication error. This affected one (Resident #35) of six residents reviewed for blood pressure medications. The facility census was 92.

Inspectors wroteBased on observation, medical record review, review of the facility's policy, and staff interview, the facility failed to ensure a resident received adaptive equipment at meals according the physician's order. This affected two (Resident #71 and #19) of two residents who received adaptive eating equipment. The facility identified ten residents (#10, #19, #31, #57, #70, #71, #72, #76, #442 and #445) who used adaptive equipment in the facility. The facility census was 92.

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain a clean, functional and safe environment for the residents. This affected four (Resident #10, #35, #36, and #71) of 92 residents residing in the facility. The facility census was 92.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure the all survey results in the past three years were available for residents, family members, and/or legal representatives of residents to review. This had the potential to affect all 92 residents residing in the facility.