W Frank Wells Nursing Home

In the surveyor’s words

From the most serious findings on record at W Frank Wells Nursing Home, in the surveyor’s own words.

• Immediate jeopardy, widespreadF835Jun 13, 2024

  Based on observations, staff interviews, resident, facility, and staff record reviews, the facility's policy Resident Elopement, the Facility Assessment, and the Administrator's job description, the facility administration failed to provide sufficient oversight, identify needed resources and ensure staff were sufficiently equipped to provide adequate supervision and implement relevant measures to prevent elopement (leaving the premises without supervision or staff knowledge) and minimize the risk of injury or death for Resident #1 and all seven of the other residents identified as at risk for elopement. […]

• Immediate jeopardy, widespreadF867Jun 13, 2024

  Based on observations, staff interviews, resident, facility, and staff record reviews, the facility's policy for Resident Elopement, the Facility Assessment, and a review of the Quality Assurance and Performance Improvement (QAPI) Program, the facility failed to have an effective Quality Assurance and Performance Improvement (QAPI) process to monitor/audit facility practices involving resident elopements, assessment of elopements, staff education and competencies, and development of effective safety and preventative measures for Resident #1, who was identified as an elopement risk, as well as seven other residents identified as at risk for elopement. […]

• Immediate jeopardy, isolatedF600Jun 13, 2024

  Based on observations, staff interviews, resident, facility, and staff record reviews, and the facility's policy for Abuse Prevention/Reporting, the facility failed to protect the resident's right to be free from neglect. The facility failed to have a systematic process in place to protect Resident #1 and all residents identified as at risk, from harm or possible death. The facility failed to identify environmental risks, revise the plan of care, and develop and implement necessary and relevant interventions to protect vulnerable residents from exiting the facility without staff knowledge and supervision. This created a likelihood that Resident #1, or any other vulnerable at-risk resident, could leave the facility undetected and suffer serious physical harm. […]

• Immediate jeopardy, isolatedF689Jun 13, 2024

  Based on observations, staff interviews, resident, facility, and staff record reviews, and the facility's policy for Resident Elopement, the facility failed to provide supervision and implement sufficient interventions to maintain resident safety, prevent elopement (leaving the premises without supervision or staff knowledge) and minimize the risk of injury or death for Resident #1 and all residents identified as at risk for elopement. The facility failed to have a systematic process in place to educate staff, identify environmental risks, revise plans of care, and develop, and implement relevant interventions to protect vulnerable residents from exiting the facility without staff knowledge and supervision. […]

• No harm, potential for more than minimal, widespreadF812Dec 5, 2024

  Based on the kitchen food service observations, staff interviews, facility document review and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness with the potential to affect all of the residents in the facility. The facility failed to ensure that the dietary staff used proper procedures for hand hygiene, disposable glove use, food storage and proper sanitation practices in the kitchen and for the two ice machines located in the main dining room and the restorative dining area. […]