Inspection Reports for Wesley Woods Rehabilitation and Healthcare

The facility failed to ensure that a resident's personal and medical records were kept private and confidential when an LVN left a computer unlocked and unattended with residents' information visible. Staff interviews confirmed the responsibility to lock computers to prevent unauthorized access, and the facility initiated inservicing on this issue.

The complaint investigation was substantiated. The investigation revealed that a staff member was frustrated with Resident #2 and used unprofessional language, including telling Resident #2 'don't touch me, there is no one here to help you.' The staff member was witnessed on camera mistreating Resident #2 and was terminated. The investigation was founded.

The facility failed to ensure Resident #2 was treated with respect and dignity during personal care, resulting in a founded abuse investigation and termination of the responsible staff member. Additionally, the facility failed to provide timely meals according to scheduled meal times for three residents, causing potential health risks.

The facility failed to provide adequate pharmaceutical services for three of five residents reviewed, including issues with medication card tampering potential due to tape on blister cards, lack of staff training on patch use, and a narcotic count sheet reconciliation error involving falsification of medication waste documentation. These deficiencies posed risks of medication errors and potential harm to residents.

The complaint investigation found that on 11/28/2024, residents #1, #2, and #3 received double doses of narcotic pain medication due to failure to sign off medication administration in the EMR and communication errors between staff. The facility did not monitor residents for adverse effects or notify responsible parties timely. Immediate Jeopardy was identified on 04/04/2025 and removed on 04/08/2025 after corrective actions.

The facility failed to maintain accurate and timely medication records, failed to follow medication administration policies, did not monitor or document residents after medication errors, and failed to notify responsible parties. An Immediate Jeopardy was identified but later removed after corrective actions and staff training were implemented.

The complaint investigation found that the facility did not notify Resident #1's responsible party of his lithium lab results that were out of range on 2/25/2025. Interviews with the charge nurse, ADONs, DON, AD, and MD confirmed the failure to communicate the lab results to the responsible party, which could affect trust and continuity of care.

The facility failed to notify Resident #1's responsible party of his out-of-range lithium lab results dated 2/25/2025. Interviews with nursing staff and administration confirmed breakdowns in communication and documentation regarding notification of the responsible party. The facility's policy states residents have the right to be informed and participate in their care, which was not upheld in this case.

The complaint involved allegations of disrespectful treatment of Resident #1, improper use of mechanical lift causing injury, and failure to follow food safety protocols. The complaint was substantiated based on video evidence, interviews, and record reviews.

The facility failed to treat a resident with dignity, improperly used a mechanical lift causing injury, and failed to ensure dietary staff wore beard restraints, posing risks of psychosocial harm, physical injury, and food contamination.

The complaint investigation was substantiated based on video evidence showing CNA A pushing Resident #1 causing a fall. The resident was not immediately assessed for injuries due to aggressive behavior, and staff left the resident unattended for about 30 minutes. Family members reviewed the video and reported the incident. The facility suspended and terminated involved staff and notified police and medical director.

The facility failed to protect Resident #1 from abuse when CNA A pushed the resident causing a fall, and failed to properly assess the resident for injuries immediately after the fall. The resident was left unattended for approximately 30 minutes, and staff did not adequately check on his condition. The facility took corrective actions including suspension and termination of involved staff and increased monitoring.

The complaint investigation revealed that LVN A failed to document medication administration in the MAR for three residents. Interviews with the Director of Nursing (DON) and Administrator (ADM) confirmed the documentation errors and lack of in-service training on medication documentation. Additionally, food service staff were found to be unfamiliar with proper food labeling and storage policies, with no in-service training provided on food handling.

The facility failed to ensure accurate documentation of medication administration for 3 residents, with medications recorded in controlled drug logs but not in the Medication Administration Record (MAR). Additionally, the facility failed to properly store, label, and date food items in the kitchen refrigerator and freezer, risking foodborne illness.

The visit was complaint-related due to concerns about inaccurate documentation and possible failure to perform catheter care as ordered. The complaint was substantiated with findings of missing documentation and potential risk to residents.

The facility failed to ensure catheter care was performed and documented as ordered for three residents (#1, #3, and #7) on multiple dates in January 2024, which could place residents at risk of infections and other complications. Interviews with staff confirmed lapses in documentation, though care was believed to be provided. The Director of Nursing acknowledged documentation issues and responsibility for oversight.

The facility was found deficient in respecting residents' rights to receive unopened mail, providing adequate nail care to residents requiring assistance, ensuring proper respiratory care including timely changing of oxygen tubing and nebulizer equipment, and maintaining an infection prevention and control program including a water management program for legionella testing.

The complaint was substantiated as the video evidence showed CNA A's unprofessional tone and demanding behavior. CNA A was suspended pending investigation but returned after no abuse or neglect was found. The facility acknowledged the need for improved communication and professionalism.

The facility failed to treat Resident #1 with respect and dignity, as CNA A did not introduce themselves, communicated in a demanding tone, and appeared frustrated during care. The investigation found no abuse or neglect but noted the need for improved communication and professionalism.

The complaint involved a physical abuse allegation where CNA A pulled a taser on Resident #1 on 04/29/2023. The Immediate Jeopardy was identified but corrected before the survey began. The facility self-reported the incident, removed CNA A, notified police and the staffing agency, and conducted assessments of the resident. Interviews with staff confirmed the incident and subsequent actions.

The facility failed to ensure a safe environment free from abuse for Resident #1 when CNA A pulled a taser to scare the resident. Immediate Jeopardy was identified from 04/29/2023 to 05/06/2023 but was corrected prior to the investigation. The facility took multiple corrective actions including removal of CNA A, staff in-service, notification of authorities, and psychological and physical assessments of the resident.

The complaint investigation found that Resident #1 was transferred to a behavioral health facility on 5/3/2023 and was not issued a 30-day discharge notice by the facility before being discharged to the resident's representative's custody on 5/18/2023. Interviews with facility staff and the resident's representative confirmed the lack of proper discharge notification and failure to inform about appeal rights or the Ombudsman. The resident's representative expressed distress over the discharge and difficulty finding alternate placement.

The facility failed to notify Resident #1 and the resident's representative in writing and in an understandable manner about the transfer or discharge, including the effective date and location. The facility did not provide a 30-day discharge notice prior to the transfer, which placed residents at risk of care disruption and discharge without alternate placement.

The facility failed to provide adequate privacy during medication administration for residents, failed to maintain proper hand hygiene during medication administration increasing infection risk, and failed to maintain a walk-in freezer in safe operating condition, creating potential safety hazards and risk to food safety.

The facility was found deficient in ensuring residents did not receive unnecessary medications, timely removal of expired medications, proper food storage and handling, and adequate infection prevention and control practices including COVID-19 screening and hand hygiene.