Deficiencies (last 3 years)
Deficiencies (over 3 years)
1.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
51% better than South Carolina average
South Carolina average: 3.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Deficiencies: 0
Date: Nov 27, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Wesley Commons Health and Rehabilitation Center, summarizing the results of a survey completed on 2024-11-27.
Findings
No health deficiencies were found during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 19, 2023
Visit Reason
The inspection was conducted as a complaint survey triggered by a resident safety incident involving entrapment in quarter side rails of a resident's bed, resulting in death. The visit included an extended survey for non-compliance related to substandard quality of care.
Complaint Details
The complaint investigation was substantiated, involving a resident who was found entangled in quarter length side rails and subsequently died. The facility was notified of immediate jeopardy related to quality of care and took corrective actions including removal of quarter side rails and staff re-education.
Findings
The facility failed to provide adequate supervision and protect one resident from entrapment in quarter side rails, resulting in death. The investigation revealed the resident was found unresponsive with her head trapped between the side rail and the wall. The facility subsequently removed all quarter side rails and implemented corrective actions including audits, staff education, and policy revisions to prevent recurrence.
Deficiencies (1)
Failure to ensure the nursing home area was free from accident hazards and provide adequate supervision to prevent accidents, resulting in resident entrapment and death.
Report Facts
Beds audited with Bionix device: 11
Beds with side rails removed: 8
BIMS score: 3
Years CNA1 worked at facility: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA1 | Certified Nursing Assistant | Observed resident entangled in side rail and reported incident; stated no in-service training on side rails prior to or after incident. |
| RN1 | Registered Nurse | Responded to resident entrapment, called 911, and provided care during incident. |
| Administrator | Conducted internal investigation, notified of immediate jeopardy, and implemented removal of quarter side rails. | |
| Director of Nursing | Present during interviews and involved in corrective action planning and staff education. | |
| Director of Therapy | Provided information on resident's mobility status and involvement in side rail assessments. | |
| LPN1 | Licensed Practical Nurse | Conducted assessments for side rail use and provided information on resident's mobility and side rail usage. |
| LPN2 | Licensed Practical Nurse | Conducted assessment for side rail use. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 14, 2023
Visit Reason
The inspection was conducted to investigate complaints related to medication errors and medication cart security at Wesley Commons Health and Rehabilitation Center.
Complaint Details
The complaint investigation revealed medication errors affecting one resident (Resident #23) and failure to secure medication carts properly. Interviews with staff including Licensed Practical Nurse (LPN1), Director of Nursing, and Administrator confirmed the errors and lapses in medication administration and cart security.
Findings
The facility failed to ensure medication error rates were below 5%, with a medication error rate of 10.71% observed during medication administration. Additionally, the facility failed to ensure that medication carts were locked when unattended, posing a risk of unauthorized access.
Deficiencies (2)
Failed to ensure medication error rates were not 5 percent or greater, with 3 errors out of 28 opportunities observed.
Failed to ensure medication carts were locked when unattended, with 1 of 4 medication carts observed unlocked.
Report Facts
Medication error rate: 10.71
Medication carts observed: 4
Medication carts unlocked: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Named in medication error findings and medication cart security observation. |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration policies and medication cart security. |
| Administrator | Administrator | Interviewed regarding medication administration policies and medication cart security. |
Inspection Report
Deficiencies: 2
Date: Sep 30, 2021
Visit Reason
The inspection was conducted to assess compliance with resident dignity and care plan requirements, specifically regarding the provision of privacy covers for urinary catheter bags.
Findings
The facility failed to provide a privacy cover for Resident 216's urinary catheter bag as required by the baseline care plan. Observations and interviews confirmed the catheter bag was uncovered and visible from the hallway, which raised concerns about resident dignity and privacy.
Deficiencies (2)
Failed to promote and maintain the dignity of Resident 216 by not providing a privacy cover for their urinary catheter bag.
Failed to develop and implement a complete care plan that meets all the resident's needs, specifically the failure to provide a privacy cover for Resident 216's urinary catheter bag per the baseline care plan.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Interviewed regarding the uncovered catheter bag and privacy cover policy. |
| Director of Nursing | Director of Nursing | Interviewed regarding facility policy and resident preference on catheter bag privacy covers. |
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