Wesley Enhanced Living Main Line Rehab and SKD NSG

In the surveyor’s words

From the most serious findings on record at Wesley Enhanced Living Main Line Rehab and SKD NSG, in the surveyor’s own words.

• Immediate jeopardy, widespreadF689Jul 31, 2024

  Based on observation, facility documentation, and clinical record review, as well as staff interviews, it was determined the facility failed to ensure the hot water dispensing machine produced water at a safe temperature resulting in actual harm to Resident R1 who sustained burns on the left thigh and groin, requiring treatment in an emergency room . This resulted in an Immediate Jeopardy, when it was determined that the facility failed to monitor the temperatures of the hot water dispensing machine and facility policy failed to identify hot beverage temperature parameters which had the potential to cause the residents discomfort or pain, to jeopardize the health and safety for 54 residents. […]

• No harm, potential for more than minimal, patternF835Jul 31, 2024

  Based on a review of their job descriptions it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to ensure the beverage temperature policy included parameters identifying safe beverage temperatures for hot liquids and failed to protect residents from potentially suffering a medical emergency related to hot beverage burns. Findings include: Review of the job description for the NHA revealed the essential function is to ensures compliance with all laws, rules, regulations, policies and procedures within the community for all levels of care. Assure highest quality medical care to residents. Ensure that all medical services implemented are consistent with WEL mission, vision, and values. […]

• No harm, potential for more than minimal, patternF689Jan 11, 2024

  Based on observations and interviews during a facility power outage, it was determined that the facility failed to ensure residents environment remained as free of accident hazards as is possible in two out of three nursing units (East and South Wings). Findings: Observations on January 10, 2024, at 9:30 a.m. revealed that the facility experienced a power outage during the night. Orange power cords (long extension cords) were in the lying, in the east and south wings of the nursing units, across the hallways into resident rooms. An interview with the Director of Nursing on January 10, 2024, revealed that the building is old and the outlets in the resident rooms were not active due to the power outage. […]

• No harm, potential for more than minimal, isolatedF757Jan 11, 2024

  Based on facility policy review, clinical record review, and staff interviews it was determined that the facility failed to provide adequate indications for use of pain medications for one of 24 residents reviewed (Resident 34). Findings include: Review of the facility policy revealed a document titled Pain Assessment and Management, dated March 2015, states the staff will document the resident's reported level of pain with adequate detail as necessary and in accordance with the pain management program. Review of Resident 34's clinical record revealed an admitted [DATE], hip fracture and aftercare of joint replacement therapy. […]

• No harm, potential for more than minimal, isolatedF580Jan 13, 2023

  Based on clinical record review and staff interview it was determined the facility failed to notify the physician about a resident's status for one of 24 residents reviewed. (Resident 59) Findings Include: Review of Resident 59's physician orders revealed an order for a PT/INR (study of the amount of time it take for blood to clot and determine the effectiveness of blood thinning medication). Further review of Resident 59's clinical record revealed the resident did not have the blood drawn as ordered. Further review of the clinical record revealed there was no documented evidence the physician was notified of the laboratory study not being completed as ordered. Interview with the Director of Nursing on January 13, 2023 at 11:00 a.m. […]