Wesley Commons Health And Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Oct 19, 2023

  Based on record review, interviews and review of the facility's policy, the facility failed to provide adequate supervision and protect 1 of 1 residents from entrapment in the quarter side rails of the resident's bed, resulting in death. Specifically, Resident (R)1 was found by staff on [DATE] at 2:30 AM unresponsive. R1's head was trapped on the inside on the side rail and her body was off the bed against the wall. On [DATE] at 5:30 PM the Administrator was notified that the failure to protect a resident from entrapment in a bed rail, that resulted in death, constituted immediate jeopardy at F689. On [DATE] at 5:30 PM the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of [DATE]. […]

• No harm, potential for more than minimal, isolatedF759Feb 13, 2026

  Based on observation, interview, record review, facility policy review, and manufacturer guideline review, the facility failed to ensure the medication administration error rate was less than 5 percent (%). The facility had 2 medication errors out of 31 opportunities, affecting 2 residents (Residents (R)48 and R65) of 8 residents reviewed during the medication administration task, resulting in a medication error rate of 6.45%. Findings include: 1. Review of the facility policy titled, Insulin Injection Administration Procedures, revised on 10/10/2024, indicated, the purpose was, To aid oxidation and utilization of the blood sugar by the tissues and to control the blood sugar levels in residents with diabetes mellitus through the correct administration of insulin. […]

• No harm, potential for more than minimal, isolatedF761Feb 13, 2026

  Based on observation, interview, facility document and policy review, the facility failed to ensure medications were stored safely and securely for 1 (Medication Cart #2) of 4 medication carts. Findings include: Review of the facility policy titled, Storage of Medications, revised on 06/07/2024, indicated, To ensure that medications are stored safely, securely and properly. Medication supply is accessible only to licensed nursing personnel and pharmacy personnel. The policy further indicated, 2. Medication rooms, carts and medication supplies should be locked or attended by persons with authorized access. During an observation and concurrent interview on 02/11/2026 at 5:26 PM, an unattended sealed blue bag was observed on top of Medication Cart #2. […]

• No harm, potential for more than minimal, isolatedF645Apr 14, 2023

  Based on interviews and record review, it was determined that the facility failed to ensure a Level I Preadmission Screening and Resident Review (PASARR) was completed accurately for 1 Resident (R)42 of 1 resident reviewed for PASARR. Findings include: During an interview on 04/12/2023 at 10:43 AM, the Administrator stated the facility did not have a PASARR policy. Review of a Clinical/Charting Snapshot revealed the facility admitted R42 on 11/07/2022 with a diagnosis of bipolar disorder. The quarterly Minimum Data Set (MDS), dated [DATE], revealed R42 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Further review of the MDS indicated the resident had bipolar disorder and took an antipsychotic medication. […]

• No harm, potential for more than minimal, isolatedF759Apr 14, 2023

  Based on observation, record review, interviews, and facility policy review, the facility failed to ensure the medication error rate was not 5% or greater. Observation of medication administration revealed there were 3 errors out of 28 opportunities observed which resulted in a medication error rate of 10.71%. This effected 1 (Resident (R)23) of 2 residents observed during medication administration. Findings included: A review of the facility's policy titled, Administration of Medication, revised 08/23/2023, revealed, when preparing medication to administer to a resident, staff should Comply with the Five Rights of Medication Administration: Right resident; Right drug; Right dose; Right time; Right route. […]