Wesley on Grand

In the surveyor’s words

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

• Actual harm, isolatedF697Dec 13, 2021

  Based on interviews, record review, and facility policy review, the facility failed to ensure staff provided pain management to residents who require such services, consistent with professional standards of practice and the residents ' goals and preferences for 1 of 2 residents reviewed (Resident #23). The facility reported a census of 65 residents. Findings include: According to the Minimum Data Set (MDS) assessment tool dated 10/05/21, Resident #23 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed Resident #23 scored 15 of 15 possible points on the Brief Interview for Mental Status (BIMS), which meant the resident displayed intact memory and cognitive abilities. […]

• Actual harm, isolatedF686Sep 8, 2021

  Based on observations, clinical record review, facility policy review, staff interviews, family interview, and physician interview; the facility failed to prevent and thoroughly assess a pressure ulcer for 1 of 3 residents reviewed (Resident #1). The facility failed to assess the area to the resident's left heel when identified on 7/21/21. The facility failed to notify the physician, the resident, and/or the resident representative with a change to the ulcer on the left heel when identified on 8/4/21. Upon admission to the facility on [DATE], and weekly thereafter, the facility failed to assess areas on the resident's right first 1st and 2nd toes. […]

• No harm, potential for more than minimal, patternF812Jun 12, 2025

  Based on observations, staff interview, and policy review the facility failed to serve food under sanitary conditions to prevent foodborne illness during one of one meal observed. Facility staff also failed to conceal hair completely in a hairnet to prevent foodborne illness. The facility reported a census of 73 residents. Findings include: Observations revealed the following: a. On 6/11/25 with lunch service starting at 11:25 AM, Staff A, Dietary Aide (DA) carried a glass of juice with her hand over the top of the glass, her fingers touching the rim of the glass and served the juice to a resident. Staff A continued to carry and serve glasses of fluids to the residents with her hand over the top of the glass. b. […]

• No harm, potential for more than minimal, patternF880Apr 20, 2023

  Based on clinical record review, observation, facility policy review, Center for Disease Control and Prevention (CDC) guidance, and staff interview the facility staff failed to remove gloves and perform hand hygiene after handling soiled linens resulting in potential cross contamination; failed to apply and remove personal protective equipment (PPE) before and after entering a COVID positive room to prevent the spread of COVID-19 for 1 of 1 residents reviewed for COVID 19 care (Resident # 59); failed to correctly wear face masks as required for community transmission rate of COVID 19; failed to appropriately sanitize blood sugar meters for 1 of 2 residents (Resident #71) observed and failed to utilize clean barriers during dressing changes of 1 of 3 resident reviewed for wound care to… […]

• No harm, potential for more than minimal, patternF725Dec 13, 2021

  Based on facility record review and interviews, the facility failed to respond to residents''' call lights in a timely manner (within 15 minutes) for 8 of 17 residents reviewed (Residents #12 #26, #28, #29, #36, #49, #53, #57). The facility reported a census of 65 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #12 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact memory and cognition. The Resident required total dependence with 2 person physical assistance for transfers and toilet use. Resident #12 required extensive assistance of 2 people for dressing and limited assistance of one person for personal hygiene. […]