Wexford Senior Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate supervision by failing to effectively identify and assess elopement risk to assure resident safety needs for one resident (Resident #4) of three residents reviewed for supervision. Findings Include:Resident #4 (R4) was admitted to the facility on [DATE] with diagnoses that included alcohol dependence with alcohol-induced persisting dementia, Wernicke's Encephalopathy (a potentially life-threatening neurological disorder caused by a severe deficiency of thiamine [vitamin B1]), and adjustment disorder with mixed anxiety and depressed mood. The Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating moderately impaired cognition. [...]

Inspectors wroteBased on interview and record review, the facility failed to honor the advanced directive for code status for one Resident (#71) of one resident reviewed for advanced directives (a legal document that allows a person to identify decisions about end-of-life care ahead of time). This deficient practice resulted in the potential for decisions regarding end-of-life care to not be honored by the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor and assess nutritional interventions and modify or implement revised interventions for one resident (#6) of two residents reviewed for nutrition with significant weight loss.

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. This deficient practice has the potential to result in food borne illness among any and all 62 residents.

Inspectors wroteBased on observation, record review, and interview the facility failed to implement enhanced barrier precautions (EBP) for six residents (Resident #4, #20, #27, #39, #63, #64) of 24 sampled residents reviewed for EBP. This deficient practice has the potential for development and transmission of multi-drug resistant organism (MDRO) infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure catheter securement devices were in place to prevent indwelling urinary catheter dislodgement for two residents (Resident #20 and Resident #64) of three residents reviewed for catheter care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure tube feeding was administered and dated per standards of practice to meet the nutritional needs of one Resident (R27) of one resident reviewed for tube feeding.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure grievances were documented, investigated, tracked and resolved for the members of the Resident Council, resulting in feeling of anger, frustration and unresolved grievances.

Inspectors wroteBased on observation and interview, the facility failed to ensure the environment was safe, sanitary and functional as evidenced by carpeting on the 200 and 400 halls being stained, torn, emanating foul odors, rippled and uncleanable. This deficient practice has the potential to contribute to falls, and a general feeling of discomfort to 64 residents living on the halls, of a total 75 residents in the facility, staff and visitors.

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately complete a Minimum Data Set (MDS) assessment for one resident (#426) of 18 residents reviewed for accurate assessments resulting in the potential for inaccurate plans of care and unmet resident care needs. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to create a COPD (Chronic Obstructive Pulmonary Disease) care plan for one resident (R40) of eighteen residents reviewed for care plans, resulting in a potential to initate goals and interventions for the resident's diagnosis.

Inspectors wroteBased on interview, and record review the facility failed to develop a discharge summary which included a recapitulation of stay for one (Resident #74) of one reviewed for discharged , resulting in the potential for the receiving caregivers to not be fully informed of the resident's history and status. According to the clinical record, Resident 74 (R74) was admitted on [DATE] with diagnoses that included pneumonia and chronic obstructive pulmonary disease. Review of the clinical record further reflected nursing progress notes dated 06/03/23 10:41 , R74 oxygen saturation level was 75% while on 2 liters of oxygen and R74 was noted to have been using accessory muscles to breath. R74 refused to be hospitalized , the family, Nurse Practitioner and Director of Nursing (DON) B were all notified, hospice services were requested by R74's son. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provided treatment (Mucinex) for one resident (R40) of three resident reviewed for respiratory care, resulting in the delaying of treatment cough and respiratory concerns (increased phlegm production and audible wheezing).

Inspectors wroteBased on interview and record review, the facility failed to change a urinary catheter per Physician order for one resident (R9) of two residents reviewed for urinary catheter, resulting in the potential for the development of a UTI (Urinary Tract Infection).

Inspectors wroteBased on interview and record review, the facility failed to documented refusals for missed dialysis treatments for one (R16) of one resident reviewed for dialysis, resulting in the potential for miscommunication for dialysis treatments missed.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement infection control practices to change oxygen tubing/nasal cannulas for two residents (51, #426) of three residents reviewed for oxygen usage resulting in the potential of residents to develop respiratory infections. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to administer pneumococcal immunizations in accordance with the Center for Disease Control and Prevention (CDC) recommendations for one residents (#17) of five residents reviewed resulting in the potential for server illness and complications from pneumococcal disease. Findings Included: Resident #17 (R17) Review of the medical record revealed R17 was admitted originally admitted to the facility 10/16/2013. She was discharged from the facility 07/25/2023 and re-admitted [DATE] with diagnoses that included sepsis, disorder of teeth, metabolic encephalopathy (brain disease or damage causing impaired brain function), constipation, anemia (low red blood cells), chronic obstructive pulmonary disease (COPD), hypertension, post-traumatic stress syndrome, adjustment disorder, depression, heart failure, and type 2 diabetes. [...]