Wylie Oaks Healthcare and Rehabilitation

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 8 residents (Resident #1) reviewed for ADLs. The facility failed to ensure staff provided consistent showers/baths for Resident #1. The facility failed to ensure Resident#1 fingernails were cleaned and trimmed. These failures could place residents at risk of not receiving needed hygiene care which could cause skin breakdown, infection, a loss of dignity and self-worth.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of 4 residents reviewed for respiratory care. The facility failed to ensure Resident #1's nebulizer mask (device used to deliver medication in a mist form through the mouth) was stored in a bag when not in use on 10/30/2025. This failure could place residents at risk of respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 10 of 15 resident rooms on the 100 hall (Resident rooms #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10), and residents eating in the dining room, reviewed for environment. 1. The facility failed to ensure Resident rooms #1, #2, #3, #5, #6, #7,#8,#9 and #10, were thoroughly cleaned and sanitized. 2. The facility failed to ensure the trash can in the dining room had a lid on it while residents were dining. These failures deficient practices could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (Resident #15 and Resident #222) of 14 residents reviewed for respiratory care. 1. The facility failed to ensure Resident #15's breathing mask (used to receive medications by breathing in mist through nose and mouth) was properly stored when not in use on 06/10/2025 and that there was an order to assess the resident before and after the breathing treatment. 2. The facility failed to ensure a sign was placed outside of Resident #222's room to indicate oxygen was in use on 06/10/2025. These failures could place residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in accordance with currently accepted professional principles for two (Resident #18 and Resident #56) of sixteen residents reviewed for pharmaceutical services. 1. The facility failed to dispose of Resident #8's expired Advair (medication inhaled to treat asthma) dated 05/21/2025. 2. The facility failed to ensure that the amount on Resident #56's Lorazepam (antianxiety medication) container was the same with the amount written on the narcotic sheet on 06/11/2025. These failures could place residents at risk of not receiving the medication's full therapeutic benefits, possible side effects, and not identifying promptly the potential loss of a controlled medication.

Inspectors wroteBased 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 development and transmission of communicable diseases and infections for two (Resident #53 and Resident #56) of ten residents reviewed for infection control. 1. The facility failed to ensure HA D wore a gown while dressing Resident #53, who had a g-tube (gastrostomy feeding tube: a tube that is surgically inserted through the skin of the belly and into the stomach), and was on enhanced barrier precautions, on 06/10/2025. 2. The facility failed to ensure that LVN H changed his gloves and performed hand hygiene when providing wound care to Resident #56 on 06/11/2025. These failures could place residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to treat each resident with respect, dignity, and care in a manner and environment that promoted maintenance or enhancement of his or her quality of life for one (Resident #53) of one resident reviewed for Confidentiality of Records. The facility failed to ensure LVN B secured Resident #53's medical information when she left her cart unattended on [DATE]. This failure could place the residents at risk of their medical information being exposed to unauthorized individuals.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 1 of 6 residents (Residents #53) reviewed for accident prevention. The facility failed to ensure HA D would not transfer Resident #53 using a Hoyer lift (a mechanical lift used to transfer an individual with limited mobility) by herself on 06/10/2025. These failures could prevent the residents from having an environment that was free and clear of accidents and hazards.

Inspectors wroteBased on observations, interviews, and record review, the facility failed the medication was labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions for one (Resident #53) of six residents reviewed for labelling of drugs and biologicals. The facility failed to ensure a change of instruction label was placed on Resident #53's Lorazepam after a change to the order. This failure could place residents at risk of wrong medication administration, mismanagement of care, adverse effects, and physical harm.

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 1 (Resident #1) of 4 residents reviewed for quality of care. On [DATE] RN A failed to monitor Resident #1 but documented doing vitals during a timeframe which she had become deceased . On [DATE] RN A insisted to Police Officer C Resident #1 was alive when he checked on her at 6:30 AM. RN A documented the vitals for Resident #1 at 7:04 AM. CMA (Certified Medication Aide) B found Resident #1 unresponsive at 7:00 AM during a routine morning medication pass. Police Officer C stated Resident #1 showed obvious signs that were incompatible with life at 7:44 AM and indicated she had most likely already been deceased prior to when RN A checked on her at 6:30 AM. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 (Resident #1) of 4 residents reviewed for accuracy of medical records. The facility failed to ensure the nursing notes accurately reflected Resident #1's condition when the ADL sheet incorrectly documented a rash on 01/03/2025 to her buttocks . These failures could place residents at risk for medication and /or treatment errors and omissions in care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the medications for four (Resident #1, Resident #2, and Resident #3) of fifteen residents were provided a safe and secured storage with limited access. 1. The facility failed to ensure Resident 1's bottle of One-A-Day multivitamins was not left on top of the resident's right side table on 10/22/2024. 2. The facility failed to ensure Resident 2's Benadryl cream was not left on top of the resident's left side table on 10/22/2024. 3. The facility failed to ensure Resident 3's zinc oxide was not left on top of the resident's left side table on 10/22/2024. These failures could place the residents at risk of not receiving medications, accidental overdose, or misuse of medications.

Inspectors wroteBased on interview, and record review, the facility failed to develop a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care that was developed within 48 hours of a resident's admission for one ( Resident #2) of three residents reviewed for baseline care plans. The facility failed to ensure Resident #2's baseline care plan was specific to the Resident #2 and contained specific instructions needed to provide effective care. This failure placed newly admitted residents at risk of not being informed of their initial goals and services, not receiving continuity of care and communication among nursing home staff, decreased resident safety and safeguard against adverse events that are most likely to occur right after admission.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choice one (Resident #1) of three residents reviewed for quality of care. The facility failed to complete a weekly skin assessment for Resident#1 This failure could place the resident at risk for diminished quality of care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that pain management was provided for 2 (Resident#4 and Resident #36) of 8 residents reviewed for pain. 1. The facility failed to provide effective pain management for Resident #36 after she experienced a fall on 05/09/2024 she was observed by staff resulting in signs of pain such as grimancing and screaming with movement. 2. The facility failed to provide effective pain management for Resident #4 when his pain medication was reduced without his knowledge resulting in him experiencing unnecessary pain and suffering and psychosocial harm. On 05/16/2024 at 4:51 PM an immediate jeopardy was identified. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to consider the views of the resident group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility for three (05/9/2024, 04/11/2024, and 03/07/2024) of three Resident Council meetings reviewed for resident group response. The facility failed to ensure prompt efforts were made by the facility to resolve grievances of the confidential Resident Council reviewed for grievances. This failure could place facility residents at risk unresolved grievances, a decreased sense of self-worth, and a decline in quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that Residents, who needed respiratory care, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for four (Resident #29, Resident #61, Resident #66, and Resident #71) of ten residents reviewed for respiratory care. 1. The facility failed to ensure Resident #29's nasal cannula was changed weekly and was properly stored. 2. The facility failed to ensure Resident #61's nasal cannula was properly stored. 3. The facility failed to ensure Resident #66's nasal cannula was properly stored. 4. The facility failed to ensure Resident #71's breathing mask for nebulization was changed weekly and properly stored. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide food and drink that was palatable and in the correct food form for two (Lunch 05/14/2024, Lunch 5/15/2024) of three meals observed for food palatability and food form. The facility failed to provide a lunch meal on 5/14/2024 and 5/15/2024 that was palatable and that had the puree bread in the correct food form. This failure could place residents at risk of decline in nutrition status, loss of appetite, and decreased intake placing them at risk for unplanned weight loss.

Inspectors wroteBased observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (Resident #16, 42, and 50) of six residents observed for infection control. 1. The facility failed to ensure that CNA B performed hand hygiene while providing incontinence care to Resident #16. 2. The facility failed to ensure that CNA E changed her gloves and performed hand hygiene while providing incontinence care to Resident #42. 3. The facility failed to ensure that CNA D performed hand hygiene while providing incontinence care to Resident #50. These failures could place the residents at risk of cross-contamination and development of infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 2 (Resident #15 and Resident #61) of eight residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #15 and Resident #61 rooms was in a position that was accessible to the residents. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for one (Resident #70) of eight residents reviewed for care plan. The facility failed to ensure Resident #70's care plan was revised to reflect person centered interventions for hydration. This failure could place the resident at risk of current needs not being met.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide the necessary services to maintain good oral hygiene to a resident who was unable to carry out activities of daily living for one of eight residents (Resident #70) reviewed for ADL care. The facility failed to provide Resident #70, who required extensive assistance, with timely oral care and sufficient fluids to keep the resident's mouth moist. This failure could place residents at risk of oral hygiene problems including dry mouth, cavities, and infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect and exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials, which included the State Survey Agency, in accordance with State law through established procedures for one of three residents (Resident #1) reviewed for abuse and neglect. The facility did not report to the State Survey Agency when Resident #1 reported allegations of abuse within 2 hours. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must have evidence that all alleged violations are thoroughly investigated and prevent further abuse, neglect, exploitation, or mistreatment while the investigation is in process for one of three (Resident #1) residents reviewed for abuse and neglect. The facility did investigate the allegation of abuse made by Resident #1. These failures could place residents at risk for injuries, abuse, and/or neglect.

Inspectors wroteBased on observation, interview, and record review the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity for two (Resident #1 and Resident #2) of 6 residents reviewed for dignity. The facility failed to ensure Resident # 1'surinary catheter drainage bag had a dignity/privacy cover. The facility failed to maintain resident dignity by labeling Resident #2's door as COVID. These failures placed residents at risk of not having their right to a dignified existence maintained and a decline in their quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #1) of 4 residents reviewed for bladder incontinence. The facility failed to ensure Resident #1's catheter bag was not on the floor. This failure could place residents at risk for UTI's and other infections.

Inspectors wroteBased observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #53) of six residents observed for infection control. The facility failed to ensure Medication Technician G (Med Aide G) donned gloves and gown prior to providing care for Resident #53, who was in contact Isolation for Extended Spectrum Beta - lactamase (ESBL) in urine. ESBL is a bacterial infection. This failure placed residents at risk of cross-contamination and infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care was provided with such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 2 residents (Resident #25 and Resident #34) reviewed for respiratory care. The facility failed to ensure Resident #25 and Resident #34 oxygen concentrators and oxygen concentrator filters remained free of sediment and debris. These failures could place residents at risk of not receiving proper delivery of oxygen, cross contamination, respiratory compromise and/or infection and residents not having their respiratory needs met. Findings Included: 1. Review of Resident #25's Face Sheet, dated 03/28/23, revealed she was a [AGE] year-old female admitted on [DATE]. [...]