Inspection Reports for
Wesley Place on Honeysuckle – Assisted Living
718 Honeysuckle Road, Dothan, AL, 36305
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
5.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
61% worse than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Mar 23, 2024
Visit Reason
The inspection was conducted based on complaints and investigations related to resident care, safety, medication administration, infection control, and facility environment concerns.
Complaint Details
The complaint investigation included allegations of unsafe resident environments, inadequate care planning for CPAP use, failure to follow care plans resulting in resident falls and injuries, improper medication administration practices, expired medications on carts, and infection control violations. Immediate jeopardy was cited related to resident #195's fall and care plan failures.
Findings
The facility was found deficient in multiple areas including unsafe and unclean resident environments, incomplete baseline care plans for residents using CPAP machines, failure to implement comprehensive care plans leading to resident injury and death, improper medication crushing without physician orders, expired medications on medication carts, inadequate infection control practices, and failure to ensure resident safety during care resulting in serious injury and immediate jeopardy.
Deficiencies (7)
Rooms on one hall had large amounts of wall material missing behind resident beds and sagging, discolored ceiling tiles.
Baseline care plans for residents using CPAP machines did not address the use of the CPAP, leading to inadequate care planning.
Failure to develop and implement a complete care plan for resident #195, resulting in a fall with serious injuries and subsequent death.
Resident #3's medication was crushed without a physician's order; resident #40's PEG site was cleaned with soap instead of ordered peroxide.
Resident #195 fell from bed during incontinent care due to failure to have side rails up and lack of two-person assistance, causing serious injury and immediate jeopardy.
Resident #395's vial of 70/30 insulin was not labeled with opened date or expiration; expired aspirin was found on medication cart.
Infection control breaches including failure to remove mask before exiting isolation room, failure to change gloves and sanitize hands during gastrostomy site care, and improper wound packing and cleaning techniques.
Report Facts
Residents affected: 8
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Fall date: 2023
Date of death: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #6 | Certified Nursing Assistant | Named in fall incident involving resident #195 |
| LPN #11 | Licensed Practical Nurse | Crushed medication without physician order for resident #3 |
| RN #18 | Registered Nurse/Clinical Coordinator | Interviewed regarding medication and care plan deficiencies |
| LPN #3 | Licensed Practical Nurse | Failed to change gloves and sanitize hands during gastrostomy site care |
| RN #4 | Registered Nurse | Used ungloved hands and hand sanitizer improperly during wound care |
| CNA #19 | Certified Nursing Assistant | Failed to remove mask before exiting isolation room |
| Director of Nursing | Director of Nursing | Notified of immediate jeopardy findings and interviewed |
| Assistant Director of Nursing | Assistant Director of Nursing | Notified of immediate jeopardy findings and interviewed |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Mar 23, 2024
Visit Reason
The inspection was conducted based on complaints and allegations regarding care deficiencies, including environmental safety, assessment accuracy, care planning, medication administration, accident prevention, medication labeling, and infection control.
Complaint Details
The complaint investigation was triggered by reports of unsafe care practices including a resident fall resulting in serious injury and death, inaccurate assessments, medication errors, and infection control breaches. The facility was cited for immediate jeopardy related to resident #195's fall and care plan failures.
Findings
The facility was found deficient in multiple areas including failure to maintain a safe and homelike environment, inaccurate resident assessments, incomplete baseline care plans, failure to implement care plans leading to resident injury and death, improper medication crushing without orders, expired medications on the cart, improper gastrostomy site care, failure to maintain accident-free environment resulting in resident injury and death, and lapses in infection prevention practices.
Deficiencies (8)
Rooms on one hall had large amounts of wall material missing behind eight residents' beds and a sagging, discolored ceiling tile.
Resident #96's Quarterly MDS assessment was inaccurately coded, failing to reflect behavioral symptoms.
Baseline care plans for Residents #196 and #198 failed to address use of CPAP machines.
Resident #195's care plan interventions for safe positioning and assistance during incontinent care were not followed, resulting in a fall causing multiple fractures and death.
Resident #3's medication was crushed without a physician's order to do so; Resident #40's PEG site was cleaned with soap instead of ordered peroxide.
Resident #195's upper side rails were not up during incontinent care and two staff were not present to assist, resulting in a fall with serious injury and death.
Resident #395's vial of 70/30 insulin was not labeled with opened date or expiration; expired Enteric Coated Aspirin was found on medication cart.
Infection prevention lapses included staff not removing masks before exiting isolation rooms, failure to change gloves and sanitize hands during gastrostomy site care, and improper wound care techniques increasing infection risk.
Report Facts
Residents affected: 8
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #6 | Certified Nursing Assistant | Named in fall incident causing injury and death to Resident #195 |
| LPN #11 | Licensed Practical Nurse | Crushed Resident #3's medication without physician order |
| LPN #3 | Licensed Practical Nurse | Failed to change gloves and sanitize hands during gastrostomy site care for Resident #40 |
| RN #4 | Registered Nurse | Used ungloved hands and hand sanitizer improperly during wound care for Resident #295 |
| RN #7 | Registered Nurse, Clinical Coordinator | Confirmed no crush order for Resident #3's medication |
| RN #14 | Registered Nurse, Clinical Coordinator | Interviewed regarding Resident #195 fall and care plan issues |
| LPN #17 | Licensed Practical Nurse | Prepared Resident #395's medications without proper insulin vial labeling |
| RN #18 | Registered Nurse, Clinical Coordinator | Interviewed about medication labeling and expired medications on cart |
| CNA #19 | Certified Nursing Assistant | Failed to remove mask when exiting Resident #53's isolation room |
| Infection Preventionist | Infection Preventionist | Interviewed regarding infection control breaches |
| DON | Director of Nursing | Interviewed regarding Resident #195 fall and care plan failures |
| ADON | Assistant Director of Nursing | Interviewed regarding Resident #195 fall and care plan failures |
Inspection Report
Deficiencies: 0
Date: May 25, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Wesley Place on Honeysuckle, indicating the results of a regulatory survey completed on May 25, 2023.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Deficiencies: 0
Date: Aug 29, 2019
Visit Reason
The document is a statement of deficiencies and plan of correction for Wesley Place on Honeysuckle, indicating the results of a regulatory survey completed on 08/29/2019.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 8
Date: Aug 30, 2018
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory standards related to resident care, environment, infection control, medication management, food safety, and housekeeping at Wesley Place on Honeysuckle nursing home.
Findings
The facility was found deficient in multiple areas including failure to ensure residents were fed with dignity and at the same time, inadequate housekeeping with unclean resident rooms and urine odor in hallways, improper incontinent care practices by CNAs, unsecured medication cart, food safety violations including improper food handling, glove use, hair net use, and food temperature monitoring, improper storage and labeling of food items, failure to keep dumpster doors closed, and lapses in infection prevention and control practices.
Deficiencies (8)
Resident #11 was not fed supper meal at the same time as roommate, violating dignity and quality of life policy.
Resident #85's room was unclean with crumbs, wet and stained carpet, and full trash in bathroom; urine odor noted on 600 Hall.
Certified Nursing Assistant failed to wash hands between glove changes and touched clean items with soiled gloves during incontinent care for Resident #85.
Licensed Practical Nurse left medication cart unlocked while unattended.
Homemaker failed to properly contain hair under hair net, used same gloves for food and non-food items, used hand sanitizer instead of washing hands, held food container against uniform, laid tongs on food then touched non-food items, and failed to recheck reheated meat temperature.
Food in dry storage (cream of wheat) was not sealed; ham in refrigerator was unlabeled; scoop left on top of flour bin.
Dumpster door was left open, risking rodent infestation.
Certified Nursing Assistant placed soiled brief on floor and used same soiled gloves to dress Resident #10 during incontinent care.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Nurses observed: 6
Residents served: 49
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Clinical Coordinator | Interviewed about feeding policy for Resident #11 | |
| Neighborhood Coordinator | Interviewed about housekeeping duties and observations in Resident #85's room | |
| Housekeeping Supervisor | Interviewed about urine odor on 600 Hall and cleaning policies | |
| Certified Nursing Assistant (EI #8) | Observed and interviewed regarding improper glove use during incontinent care for Resident #85 | |
| Certified Nursing Assistant (EI #9) | Interviewed regarding glove use and contamination risks during incontinent care | |
| Infection Control Nurse (EI #15) | Interviewed about infection control policies and glove use | |
| Licensed Practical Nurse (EI #2) | Observed leaving medication cart unlocked and interviewed about policy | |
| Homemaker (EI #3) | Observed and interviewed about food handling and hygiene practices | |
| Certified Nursing Assistant and Homemaker (EI #4) | Observed and interviewed about food temperature monitoring and hair net use | |
| Registered Dietitian (EI #11) | Interviewed about homemaker duties and food safety training | |
| Cook (EI #14) | Interviewed about food storage, labeling, and dumpster door responsibility | |
| Certified Nursing Assistant (EI #5) | Observed placing soiled brief on floor and interviewed about glove use during incontinent care for Resident #10 |
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