Wadsworth Glen Health Care and Rehabilitation Cent

In the surveyor’s words

From the most serious findings on record at Wadsworth Glen Health Care and Rehabilitation Cent, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Nov 10, 2021

  Based on clinical record review, review of facility documentation, review of the hospital record, interviews, and policy review, for 1 of 3 sampled residents reviewed for pressure ulcers (Resident (R) #1) the facility failed to assess a heel wound on an ongoing basis and failed to follow the resident's care plan which resulted in hospitalization and an emergent above the knee amputation which resulted in immediate jeopardy. The findings include: Resident # 1's admission nursing assessment dated [DATE] identified the resident's skin, including both feet were intact. The interim care plan dated 8/11/21 identified the resident was at risk for skin breakdown related to impaired mobility, [CONDITION(S)], diabetes, and [CONDITION(S)]. […]

• Actual harm, isolatedF686Jun 14, 2023

  Based on clinical record reviews, observations, review of facility's documentation and interviews for one of three sampled residents (Resident #17) reviewed for facility acquired pressure ulcers, the facility failed to ensure interventions were consistently implemented to prevent the development and worsening of a pressure ulcers/injury. The findings include: Resident #17 had diagnoses that included cerebral infarction, hemiplegia and hemiparesis, paroxysmal atrial fibrillation, seizures, Parkinson's disease, congestive heart failure, iron deficiency anemia, dysphagia, type 2 diabetes mellitus, and protein calorie malnutrition. The Norton_Scale (used to predict risk for pressure ulcer development) dated 1/24/23 identified the resident was at high risk for pressure ulcer development. […]

• Actual harm, isolatedF697Jun 14, 2023

  Based on clinical record review, review of facility's documentation and interviews for one sampled resident (Resident #194) reviewed for pain management and was assessed as having a severe level of pain, the facility failed to ensure the resident was provided pain medication within a reasonable timeframe. The findings include: An entry tracking MDS identified Resident #194 was admitted to the facility from an acute care hospital on 4/11/22. Resident #194's diagnoses included effusion of the left and right knee, pyothorax, type 2 diabetes, hypothyroidism, nontoxic goiter, malignant neoplasm of the pancreas, iron deficiency anemia, pain, and Lyme disease. The hospital discharge summary dated 4/11/22 identified Resident #194 was seen for a fall sustained at the resident's home. […]

• No harm, potential for more than minimal, patternF803Aug 11, 2025

  Based on observations, interviews, facility documentation, and facility policy the facility failed to ensure that the dietician reviewed and approved menus and failed to ensure portion sizes were included on posted menus. The findings include:Observation on 8/4/2025 at 11:50 AM of the facility's posted menu in the kitchen area identified breakfast entrees included cream of wheat, a donut, and scrambled egg; lunch entrees included baked chicken with rice, baked ham with seasoned zucchini and onions, boiled potatoes with parsley, a dinner roll, and peaches and cream; dinner entrees included vegetable and cheese quiche with chef's vegetable, oven browned potatoes, and dinner roll , BBQ pork on a bun with coleslaw, and sherbet. […]

• No harm, potential for more than minimal, patternF804Aug 11, 2025

  Based on observation, interviews, and a temperature test, for sampled residents (Resident #1, Resident #2, Resident #38, Resident #45, Resident #66, Resident #70 and Resident #76) reviewed for dietary services, the facility failed to ensure that food was palatable and failed to serve food at a safe and appetizing temperature. The findings included:1. Resident #1's diagnoses included fracture of the left patella, fracture of the left femur, and Type 2 diabetes mellitus.Interview with Resident #1 on 8/5/2025 at 10:48 AM identified he/she found the quality of the food to be terrible and that the food was served cold. […]