Susanna Wesley Health Center

In the surveyor’s words

From the most serious findings on record at Susanna Wesley Health Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812Feb 15, 2024

  Based on observation, interview, and record review the facility failed to ensure the Third Floor Pantry refrigerator used exclusively for the resident's was maintained in a sanitary manner as evidenced by opened undated milk carton observed. This has the potential to affect fifty-five residents out of fifty-seven residents who eat orally residing on the Third floor. The findings included: Observation of the Third Floor Nourishment Pantry on 2/14/2024 at 7:33 AM revealed a pint carton of 2% reduced milk was opened and not dated. Photographic evidence submitted. Observation and interview with Staff C, Registered Nurse (RN), Nursing Supervisor on 2/14/2024 at 7:34 AM. She confirmed the milk carton was open and not dated. She stated, I forgot to check the refrigerator. […]

• No harm, potential for more than minimal, patternF921Feb 15, 2024

  Based on observations, interview, and record review the facility failed to provide a safe environment for residents on the second floor, as evidenced one out of one Biohazard room observed on the facility's second floor door was kept unlocked. This has the potential to affect the 58 residents residing on the second floor during the survey. The findings included: On 02/14/2024 at 10:15 AM The door of the Biohazard room on the second floor was not locked. On 02/14/2024 at 10:15 AM, Staff B observed entering Biohazard room by pushing the door open. The Biohazard room door unlocked while staff inside. On 02/14/2024 at 10:20 AM; One staff member observed pushing the door of the Biohazard room open and entering. The Biohazard room door was unlocked while staff inside. […]

• No harm, potential for more than minimal, isolatedF689Jul 10, 2026

  Based on observations, record reviews, and interviews, it was determined that the facility did not maintain a safe environment free from potential accident and hazards and did not provide sufficient supervision to prevent potential accidents for 1 of 24 sampled residents (Resident #23). Resident #23 was left unsupervised with an unsecured disposable razor placed on the bedside nightstand for several hours. This lapse in protocol elevated the risk for Resident #23 to experience injuries such as cuts, which could result in infection or other medical complications. At the time of the survey, there were 119 residents residing in the facility.The findings included:Observation on 07/07/2026 at 10:35 AM, revealed Resident #23 lying in bed watching television. […]

• No harm, potential for more than minimal, isolatedF867Jul 10, 2026

  Based on observations, interview and record reviews, the facility's Quality Assurance and Assessment (QAA)/QAPI) committee failed to demonstrate that an effective plan of action was implemented to correct identified quality deficiencies in the problem area related to repeated deficient practice for F689 - Free of Accident Hazards/Supervision/Devices. The facility was cited for F689 on 6/12/2025. The repeated deficient practice had the potential to affect any of the 119 residents residing in the facility at the time of the survey.The findings include:Record review of the facility's survey history revealed, during a Recertification Survey conducted on June 9, 2025, through June 12, 2025, at the facility, F689- Free of Accident Hazards/Supervision/Devices was cited due to the facility's… […]

• No harm, potential for more than minimal, isolatedF583Jun 12, 2025

  Based on observations, interviews and record reviews the facility failed to protect residents' information on the third floor as evidenced by, an observation of a computer screen unattended with residents' information visible and easily accessible. There were 118 residents residing in the facility at the time of survey. The findings included: On 6/12/25 at 10:28 AM while ambulating along the third floor hallway, the observed a the screen of an unattended computer with residents' information visible. Interview on 6/12/25 at 10:33 AM Staff J, Registered Nurse (RN) was asked about protecting resident information and protocol for the computer screen when unattended. Staff , RN stated: The cart is to be locked, and the computer is screen is to be closed when I walk away. […]