Every finding on record at Wesley on Grand

Des Moines, Iowa · CCN 165487

31 findings across 17 inspections, in the inspector's own words, 13 of them at actual harm or above.

Data as of September 30, 2026, released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.

Based on record reviews and interviews, the facility failed to document narcotic counts to ensure accurate reconciliation accounting for all controlled narcotic medications for 2 of 2 medication carts reviewed. The facility reported a census of 65 residents. Findings include: Observation of the narcotic count on 12/01/21 at 10:11 AM revealed the Sunshine Unit's November 2021 narcotic sign-out sheets lacked nurse's initials for 14 of 120 opportunities the Northshore unit's sheet lacked 11 of 120 opportunities for November 2021. On 12/01/21 at 10:10 AM Staff C, LPN stated she counted narcotics as required, but did not always sign the narcotic log as required. On 12/01/21 at 10:05 AM Staff B stated she counted narcotic at the beginning and at the end of each shift. She showed how she signed the narcotic log this morning but the nurse on the shift over night failed to do so. On 12/01/21 at 10:32 AM, the Director of Nursing (DON) stated she expected nurses to count narcotics at both the beginning and at the end of their shift and document they completed the count. The Controlled Substances Count facility policy directed one authorized person as responsible for narcotic utilization every shift. Going off duty and coming on duty, authorized persons must count and validate accuracy of the narcotics supply for every resident at the change of every shift, and reconcile by a physical count of the remaining narcotic supply at the change of each shift by the oncoming and outgoing licensed nurse/designee. After the supply is counted and justified, each nurse must record the date and his/her signature verifying that the count is correct.

F761E · No harm, potential for more than minimal, pattern

Based on observations, staff interviews, and facility policy review, the facility failed to ensure staff stored drugs in accordance with currently accepted professional principles. The facility also failed to ensure narcotic keys were only accessible to authorized personnel. The facility reported a census of 65 residents. Findings include: 1. Review of medication room refrigerator on 12/1/21 at 9:30 AM revealed 2 vials of [MEDICATION(S)] 5tu/0.1ml expired on 9/29/21, three case of Covid 19 virus collection tubes expired 6/22/21, 1 case of Remel Microtest M4RT transport 3.0ml vials expired 11/22/21, and 2 vials of Influenza vaccine opened 10/23/21. Interview on 12/1/21 at 0935 AM with Director of Nursing (DON) stated that she checked all the medication carts but forgot to check refrigerators in the medication room for expired medications. She stated her expectations are that nursing administration complete monthly audits of medication carts and medication rooms to remove all expired medications. An interview on 12/06/21 at 04:05 PM with DON revealed that pharmacy representatives audit medication carts and medication rooms for expired medications on a monthly basis. The undated facility policy titled Disposal of Medication stated all medications that are expired, discontinued, or are remaining after a resident's discharge or death will be disposed of as per procedure. 2. Observation on 12/01/21 at 08:04 AM revealed narcotic keys locked in top drawer of medication cart while Staff C delivered medications to 4 separate residents. Interview with Staff D, Certified Medication Assistant (CMA) on 12/7/21 at 09:05 AM revealed that about 1 month ago, CMA's were allowed to administer narcotic, but the facility recently changed that policy. She said that since that time, she no longer sees narcotic keys locked in the medication drawers. On 12/01/21 at 10:30 AM, the Director of Nursing (DON) stated she expected authorized nurse professionals passing medications to keep narcotic keys with them during their shift. The facility's policy reviewed 12/2021 and titled Controlled Substances Count instructed: The narcotics key is to be carried at all times by authorized personnel.

F805E · No harm, potential for more than minimal, pattern

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure staff served appropriate food textures for residents that required a mechanical soft diet for 6 of 6 residents reviewed (Resident #12, #14, #19, #36, #41, and #42). The facility reported a census of 65 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment tool dated 9/21/21, Resident #12 had diagnoses that included metabolic [CONDITION(S)], gastro-[CONDITION(S)] reflux disease without esophagitis, and anxiety disorder, unspecified. The MDS revealed Resident #12 scored 15 of 15 possible points on the Brief Interview for Mental Status (BIMS), which meant the resident exhibited intact cognitive abilities. The MDS documented the resident ate independently after set-up assist from staff and also required a mechanically altered diet (change in texture of food or liquids). On 12/1/21 at 12:39 PM, Staff F prepared the resident's Styrofoam to-go lunch box by placing a full slice of leaf lettuce on the sandwich. The Diet Type Report printed on 11/29/21 documented that the resident required a mechanical soft diet. 2. The MDS assessment dated [DATE] documented Resident #14 had diagnoses that included dysphagia, oropharyngeal phase, moderate protein-calorie malnutrition, and need for assistance with personal care. The MDS showed the resident had a BIMS score of 1, which indicated the resident demonstrated severely impaired cognitive skills. The MDS identified the resident required supervision of one staff with eating. On 12/1/21 at 12:09 PM Staff F, prepared the resident's lunch plate by placing a full slice of leaf lettuce on the sandwich, placing steamed cabbage on the plate, and then cutting the sandwich into fourths. The Diet Type Report printed 11/29/21 documented that the resident required a mechanical soft diet with cut meat and gravy. 3. According to the MDS dated [DATE], Resident #19 had diagnoses that included dysphagia following other [CONDITION(S)] disease, dysphagia, oropharyngeal phase, and need for assistance with personal care. The MDS showed the resident scored a 1 of a possible 15 points on the BIMS test, which meant the resident exhibited severe cognition impairment. The MDS documented the resident required supervision with set-up assist to eat, but the resident ate independently after set-up. The resident required a mechanically altered diet. On 12/1/21 at 12:11 PM Staff F, prepared the resident's plate with the resident's lunch by placing a full slice of leaf lettuce on the sandwich. The Diet Type Report printed 11/29/21 documented Resident #19 required a mechanical soft diet with cut meat with gravy. Additional directions directed the resident required extra gravy on her meat. 4. According to the MDS dated [DATE], showed Resident #36 had diagnoses that included [CONDITION(S)], unspecified organism, [CONDITION(S)], site not specified, and neuromuscular dysfunction of bladder, unspecified. The MDS documented the resident scored 15 of 15 possible on the BIMS, which meant the the resident displayed intact cognitive abilities. The MDS also documented the resident required assist of 2 staff for transfers and toilet use and supervision with set-up assist for eating. On 12/1/21 12:19 PM Staff F, prepared the resident's plate with the resident's lunch by placing a full slice of leaf lettuce on the sandwich. The Diet Type Report printed 11/29/21 documented that the resident required a mechanical soft diet. 5. According to the MDS dated [DATE], Resident #41 had diagnoses that included dysphagia following other [CONDITION(S)] disease, [CONDITION(S)], unspecified, and need for assistance with personal cares. The MDS documented staff could not assess the resident's BIMS score or mental status. The MDS revealed the resident required supervision with set-up assist for eating, but could eat independently after set-up and also required a mechanically altered diet. On 12/1/21 at 11:59 AM Staff F explained the resident could have lettuce, but not the other hamburger toppings as she dressed the resident's burger with a full slice of leaf lettuce. Staff F reported she gave the resident the steamed cabbage because the rest was too hard for her to chew with the salad. The Diet Type Report printed 11/29/21, documented the resident required a mechanical soft diet with ground meat and with gravy. 6. According to the MDS dated [DATE], Resident #42 had had diagnoses that included dysphagia, oropharyngeal phase, need for assistance with personal care, and need for continuous supervision. The MDS revealed the resident scored 15 of 15 possible on the BIMS, and required set-up assist and supervision with eating. The MDS showed the resident required a mechanically altered diet. On 12/01/21 at 12:25 PM Staff F, prepared the resident's by placing a full slice of leaf lettuce on the sandwich. The Diet Type Report printed 11/29/21 documented the resident required a mechanical soft diet ground meat with gravy. On 12/2/21 at 12:49 PM, the Dining Director reported residents that eat a mechanical soft diet could have finely shredded lettuce. The policy showed advanced dysphagia #3 listed on diet spreadsheet to indicate the resident required a mechanical soft diet. The Dining Director added residents would receive an alternate of steamed cabbage for coleslaw if they were on a mechanical soft diet. On 12/2/21 at 2:40 PM, the Dietician reported staff should serve shredded lettuce for residents that require a mechanical soft diet. She added if the facility's spreadsheet or recipe showed lettuce, she would expect there would be food to use with a smaller particle texture. The undated Mechanical Soft Diet directed individuals with difficulty chewing and the ability to tolerate a wide variety of foods ate a mechanical soft diet, which was designed to permit easy chewing. The policy recommended staff to provide vegetables that were soft, cooked, tender, chopped, and shredded vegetables, creamed corn, vegetable juice, or shredded lettuce.

F812E · No harm, potential for more than minimal, pattern

Based on observations, staff interviews, and facility policy review, the facility failed to serve food in accordance with professional standards for food service safety, and also failed to practice proper hand hygiene during the lunch meal service. The facility reported a census of 65 residents. Findings include: Observations revealed the following: 1. On 11/30/21 at 11:59 AM, Resident #14 dropped silverware, a facility employee picked it up and placed it into the dirty dishes. Then, without completing hand hygiene, the employee reached into the into cooler to obtain some cottage cheese and then delivered it to Resident #14. On 12/1/21 at 11:01 AM, Staff F, Server, wore a fabric mask with her nose exposed at times as the mask was very loose around her face. On 12/1/21 at 11:14 AM, Staff F threw away trash and then changed gloves, but did not practice hand hygiene prior to checking food temperatures. On 12/1/21 at 11:17 AM, Staff F again changed gloves and again did not practice hand hygiene prior to checking food temperatures. On 12/1/21 11:18 AM, Staff F reached into a bag with her gloves on and obtained more wipes to clean the thermometer. Staff F changed her gloves again and without hand hygiene continued to check food temperatures. On 12/01/21 11:21 AM, Staff F changed her gloves again and without hand hygiene continued to check the temperatures of the food. On 12/1/21 11:26 AM, Staff F washed her hands, turned off the water after five seconds, and then dried her hands. On 12/1/21 at 11:30 AM, Staff E washed her hands, turned off the water with her bare hand, then obtained a paper towel to dry her hands. On 12/1/21 at 11:34 AM, Staff F washed her hands for five seconds, turned off the water with her bare hands, then dried her hands with a paper towel. On 12/1/21 at 11:47 AM, Staff G dropped a menu on the floor, picked it up, and placed the menu back on the pile of other menus on the counter located where the plates were set for serving. On 12/1/21 at 11:47 AM, Staff G adjusted her goggles with gloves on her hands and did not complete hand hygiene. On 12/1/21 at 11:48 AM, Staff G took a resident's menu, adjusted her face mask with her gloves on, and then continued to take the order while wearing the same gloves. On 12/1/21 at 11:49 AM, Staff F adjusted the menus for the residents, removed her gloves, washed her hands, turned off the water with her bare hands, and dried her hands with paper towels. On 12/1/21 at 11:57 AM, Staff F changed gloves without completing hand hygiene On 12/1/21 at 12:01 PM, Staff F changed her gloves and without hand hygiene, placed a bun on the plate with gloves, topped the grilled chicken sandwich, and placed the plate in the window with the menu. On 12/1/21 at 12:03 PM, Staff F obtained a new plate and then applied a bun to plate with the same gloves. Staff F used a gloved hand to flip over the grilled chicken sandwich. On 12/1/21 at 12:04 PM, Staff F placed a wet menu on the ledge, changed her gloves without completing hand hygiene, and then placed a bun on the plate with her gloved hands. On 12/1/21 at 12:08 PM, Staff F changed her gloves without hand hygiene and placed a bun on the resident's plate with her gloved hand. On 12/1/21 at 12:44 PM, Staff F washed hands for 10 seconds, turned off the water with her bare hand, dried her hands, and then applied gloves. On 12/2/21 at 2:40 PM, the Dietician said she wanted to discourage staff from using gloves when serving or preparing foods and didn't want bare hand contact with food. The Dietitian explained she expected staff to wash hands between tasks or when removing gloves and always use a barrier. The undated Disposable Glove Usage policy directed staff must never use gloves in place of handwashing. The procedure directed staff to wash and dry their hands before and after donning disposable gloves, and Food Handlers must change gloves at all of the following times A. When gloves become dirty or torn B. When moving from one task to another C. Before handling ready-to-eat food

F880E · No harm, potential for more than minimal, pattern

Based on clinical record review, observations, resident and staff interviews, and facility policy review, the facility failed to ensure staff staff followed accepted infection control techniques while providing catheter care for 3 of 5 residents reviewed (Residents #36, #53, and #113). The facility reported a census of 65 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment tool dated 9/22/21, Resident #36 readmitted to the facility following an acute hospital stay on 9/8/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident scored 15 of 15 possible points on the Brief Interview for Mental Status (BIMS) test, which meant the resident demonstrated intact cognitive abilities. The MDS also documented the resident required assist 2 staff for transfers and toilet use and extensive assist of 1 staff for personal hygiene. The MDS revealed the resident utilized an indwelling catheter for urinary elimination, had a urinary tract infection ([CONDITION(S)]) within the last 30 days, and required oxygen therapy. Observation on 11/30/21 at 1:06 PM, revealed Staff M, Certified Nursing Assistant (CNA), and Staff D, Certified Medication Aide (CMA), assisted the resident up from his wheelchair to move him to bed, while leaving the catheter bag in the resident's wheelchair. Staff D then placed the catheter bag on floor in the dignity bag. Staff D moved the resident's feet and catheter bag into the bed with the resident. After ensuring the resident's comfort, staff then placed the catheter on the bed frame. The Care Area Assessment (CAA) dated 9/15/21 explained the resident had an indwelling catheter due to diagnosis. The IM Progress Note dated 9/2/21 documented the resident was admitted on [DATE] with blood in his catheter and subsequently diagnosed with [CONDITION(S)] and [CONDITION(S)] due to gram-negative bacteremia. The physician ordered [MEDICATION(S)] for seven days. The Discharge Summary dated 9/8/21 revealed the resident required two different antibiotics and also a urology consult for gross hematuria, acute kidney injury, and [CONDITION(S)]. The Care Plan dated 5/10/21 documented the resident admitted with an indwelling catheter due to a [CONDITION(S)] bladder. The interventions dated 9/8/21 directed staff: A. Position the resident's catheter bag and tubing below the level of the bladder and away from the door to the room. B. Monitor for signs or symptoms of frequency and discomfort upon urination. C. Monitor/document for pain or discomfort due to catheter. D. Monitor, record, and report to the physician signs or symptoms of [CONDITION(S)] such as pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. The Care Plan dated 11/26/21 documented the resident required oxygen therapy related to post COVID-19 effects. The Care Plan dated 11/23/21 documented the resident as at risk of infections due to history of [CONDITION(S)]. A goal documented the resident would be free from complications related to an infection through the review date. An intervention dated 11/23/21 directed staff to maintain universal precautions when providing resident care. 3. According to the MDS dated [DATE], Resident #53 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident scored 15 on the BIMS and required extensive assist of one staff for toilet use. The MDS also documented the resident used an indwelling catheter for urination. In an interview on 11/30/21 at 10:29 AM, the resident reported that she had lots of UTIs and commented the nurse just took a sample the night before because they thought she had one. On 11/30/21 at 10:20 AM, observation revealed the resident's catheter bag hung from the bed without a dignity bag. Observation on 11/30/21 11:25 AM revealed Staff K washed her hands, applied gloves, and adjusted her mask twice. Without completing hand hygiene or changing her gloves, Staff K moved the tray table, picked up the wipes and graduate from the tray table, and then wiped the drainage tube of the catheter. Staff K then emptied the urine from the catheter into the graduate container. Then, Staff M handed Staff K another alcohol wipe, then Staff K cleaned the catheter tubing and closed the drainage tube. The resident told Staff K thank you for cleaning that because no one else does it. The Care Plan Problem dated 11/21/21 indicated the resident had an indwelling catheter due to non-compliance and chronic history of skin breakdown. An intervention dated 9/3/20 directed staff to monitor, record, and report to the physician signs or symptoms of [CONDITION(S)] such as pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. 4. According to the MDS dated [DATE], Resident #113 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident scored 14 of 15 possible on the BIMS test which meant the resident exhibited intact cognition. The MDS also documented resident required extensive assistance of 2 staff with toilet use, extensive assistance of 1 staff for personal hygiene, and utilized an indwelling catheter for urinary elimination. On 11/29/21 at 3:37 PM, Resident #113 sat in his recliner while his catheter bag hung from the garbage can without a dignity bag. The CAA dated 3/4/21 documented the resident needed assistance with his suprapubic catheter. The Care Plan dated 3/15/21 documented the resident had a suprapubic catheter due to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The intervention dated 11/21/21 explained the resident had a suprapubic catheter and directed staff to provide catheter cares in accordance with facility protocol. The Care Plan dated 11/22/21 documented the resident as at risk of infection due to a history of [CONDITION(S)] and an abscess. An intervention dated 11/22/21 directed staff to maintain universal precautions when providing resident cares. On 12/8/21 at 4:06 PM, the Director of Nursing (DON) stated she expected staff to place a resident's catheter bag in a dignity bag and not position the bag too high (below the bladder). She explained staff should not place a catheter on the floor without a privacy bag or hang the catheter bag from the garbage can. The DON said she also would expect staff not touch their mask without washing their hands before emptying a resident's catheter.

F550D · No harm, potential for more than minimal, isolated

Based on interviews and record review, the facility failed to ensure staff treated residents with respect and dignity while providing cares for 1 of 24 residents reviewed (Resident #29). The facility reported a census of 65 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #29 demonstrated both short and long term memory problems, was rarely or never understood, exhibited physical and verbal behaviors that affected others on 4-6 days during the 7 day lookback period, and rejected evaluation of care for 1-3 days during the 7 day lookback period. The MDS documented the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/2/21 at 3:10 PM, Staff R, Registered Nurse (RN) and 2nd Floor Nurse Manager stated that Staff Q, Agency Certified Nursing Assistant (CNA) reported she witnessed another agency CNA, Staff P strike the bottom of Resident #29's foot while providing care toward the end of the shift. Staff R reported Staff Q said she didn't know what to think about it, it made her feel uneasy, and she felt like she needed to tell someone, but added Staff Q did not tell her about it until a couple of days later. Staff R then informed the Administrator and then she helped assist with conducting the investigation. Staff Q told her the resident had some days when she had clear moments, but did not always respond appropriately. The resident could be reluctant and reject cares and sometimes she did not want to get out of bed or did not want someone bugging her. However, Staff Q said if staff explained what they were going to do and took their time, she could be cooperative. On 12/6/21 at 8:26 PM, Staff K, CNA reported she heard yelling and went into Resident #29's room. She saw one CNA standing there as if she could not believe what was happening, the resident was kicking, and the other CNA (Staff P) appeared super frustrated, and was forcibly pushing the resident's legs down. Staff K said she shooed Staff P away from the resident and then she took over the situation. Staff K commented when she came into the room, the resident saw her and calmed down a little, which diffused the situation; the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/7/21 at 10:39 AM, the Staffing Agency Human Resources representative reported the Agency's policy dictated an employee could not work if they were under investigation; they were off until the investigation was completed. The Staffing Agency Human Resources representative reported Staff P had been investigated previously by another facility in the late summer or early fall. On 12/7/21 at 8:56 AM, Staff L said that the resident could be difficult to work with at times, but if that occurred, Staff L would leave and come back later if the resident was being difficult. Staff L said that sometimes one staff member would hold the resident's arms while the other one completed cares to help protect the resident from getting hurt. On 12/8/21 at 4:06 PM, the Director of Nursing (DON) stated that she expected staff to treat every resident with respect and dignity.

F608D · No harm, potential for more than minimal, isolated

Based on record review, staff and resident interviews, and facility policy review, the facility failed to notify proper officials of reasonable suspicion of a crime and unexplained loss of money for 1 of 1 resident reviewed (Resident #23). The facility reported a census of 65 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #23 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident demonstrated intact memory and cognitive abilities. The MDS documented the resident required no set up or physical help from staff for transfers, dressing, toilet use, and personal hygiene. Record review revealed: a. On 8/24/2021 at 1:38 PM, a social services note revealed Staff N, Social Worker (SW) met with Resident #23 to ask some questions regarding concerns/inconsistencies in his banking statements. There were withdrawals with the use of his bank card and web withdrawals identified since his admission to the facility. Resident #23 did not know what the charges were for and verified he had never allowed anyone to use his debit card that he kept in his wallet. Staff N consulted the Director of Social Services regarding the financial concerns. The notes documented they determined from the perspective of a referral to Department of Human Services (DHS) for financial exploitation, Resident #23 met the criteria for being a dependent adult, but the acquaintance the facility suspected of taking the money was not a caretaker. Staff N and the Director of Social Services did not think it met the criteria of a criminal case and asked the bank to investigate. b. On 12/1/2021 at 01:57 PM, a social services note revealed Staff N, SW assisted Resident #23 to call his bank and they found he carried an un-activated debit card in his wallet and someone used a different debit card to access his bank account, potentially taking thousands of dollars from him. Staff N, SW documented Resident #23 never gave his card to anyone to use. When Resident #23 told them he had been at the facility since 4-28-21 and had not accessed his account with a debit card since then, the bank canceled the card immediately and informed him they planned to file fraud charges. The bank also told him it could take 45-90 days for the investigation to take place. In an interview on 12/02/2021 at 02:28 PM, Staff N, SW stated the bank informed her of the missing money during a phone call on 12/1/21. When asked why the facility did not report a suspicion of financial exploitation to authorities, Staff N, SW said she did not think the Resident's case needed a DHS referral because the person the facility believed responsible for taking the Resident's money was not a caregiver. Staff N stated she consulted with the Director of Social Services and the Administrator to make sure they agreed. Staff N said wanted the bank to report the suspected fraud to law enforcement since they had all of the records and the specifics of the card use. Staff N estimated the amount of money missing as between $5,000 and $10,000 and added someone had been using Resident #23's card since September of 2021 and he did not know it, but the facility knew by at the bank statements how much was withdrawn and where. Staff N said the resident's debit card always had his card with him at the facility in his wallet. Staff N, SW reported she asked the bank several times to investigate the Resident's account. Staff N, SW mentioned she spoke with a bank representative in August and asked them to initiate an internal investigation. In an interview on 12/02/21 at 01:59 PM, the Director of Nursing (DON) stated she expected staff to report large amounts of missing money to the manager on duty if staff had suspicion of someone stealing money from a resident. The DON said the SW would start an investigation and then submit it to the DON or Administrator and then someone in management would need to notify the police. In an interview on 12/02/21 at 03:59 PM, the Administrator stated he did not think that staff ever told him they suspected someone of stealing money from Resident # 23. The Administrator reported the facility educated staff if a resident reported a missing item, they were to report it to nurse manager, DON, or Administrator and from there the facility would follow policies on what to report. In an interview on 12/06/21 at 1010 AM, the Administrator stated the bank reported to their fraud unit, but not to the police. In an interview on 12/06/21 at 11:15 AM, Resident #23 stated he was in charge of his own finances and had not received a statement since he moved to the facility. He said he knew of suspected missing funds from his account and he thought someone used an old card. Resident #23 reported he did not give anyone the pin and did not give anyone permission to use his money. Resident #23 said the bank suspected his friend from a previous residence used it and added his friend had not come to visit since he became aware of money missing from his account. He said he wanted to believe his friend did not take any money from him, but he was not sure. The facility policy titled Abuse Policy/Resident Protection Plan revised 05/2021 documented upon admission and periodically thereafter, each resident will be assessed as to susceptibility to maltreatment. Residents will also be evaluated for any abusive potential toward themselves, other residents and employees. Notify the Administrator and DON immediately and other officials in accordance with state law. If it appeared there was reasonable suspicion that the maltreatment may involve a crime, the Executive Director, Administrator and DON would notify the police. Any team member who had reasonable cause to believe that a resident had been the victim of dependent adult abuse/maltreatment must report suspected maltreatment/dependent adult abuse of a resident. If a family member or resident representative is possibly contributing to the potential abuse and the resident could be at risk, evaluate the situation and identify options to put into place for resident protection including notification of law enforcement and/or state agencies as indicated. It was the policy of the Facility that abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State law. Local law enforcement would be notified of any reasonable suspicion of a crime against a resident.

F610D · No harm, potential for more than minimal, isolated

Based on record review, interviews, and facility policy review, the facility failed to prevent further financial exploitation from occurring while the facility had reasonable suspicion thereof for 1 of 1 residents reviewed (Resident #23). The facility reported a census of 65 residents. Findings include: Record review revealed the following information: a. On 8/24/2021 at 1:38 PM, a social services note revealed Staff N, Social Worker (SW) met with Resident #23 to ask some questions regarding concerns/inconsistencies in his banking statements. There were withdrawals with the use of his bank card since his admission to the facility,, and also some large web withdrawals for $2,000 from May to June 2021. Resident #23 said he did not know what the charges were for, since he kept his debit card in his wallet and had never allowed anyone to use it. Staff N, SW consulted with the Director of Social Services and the notes documented they determined that Resident #23 clearly met the criteria for being a dependent adult from the perspective of a referral to Department of Human Services (DHS) for financial exploitation. Staff N, SW documented the facility suspected one of the resident's acquaintances used his debit card, but since this person did not meet the caretaker criteria, they did not report the allegation of theft to DHS. Staff N, SW documented they did not think they had enough evidence to show that a crime occurred, but thought they could possibility speak to the bank to see if they had anyone internally that could investigate his account. b. On 12/1/2021 at 01:57 PM, a social services note revealed Staff N, SW assisted Resident #23 to call his bank. Resident #23 learned that someone had potentially taken thousands of dollars from him because the resident carried an un-activated debit card in his wallet and someone used a different debit card to access his bank account. The bank canceled the card immediately after the resident #23 told them he had been at the facility since 4-28-21 and had not accessed his account with a debit card since then. The bank stated they would file fraud charges and said it could take 45-90 days for the investigation to take place. In an interview on 12/02/2021 at 02:28 PM, Staff N, SW stated she learned of money missing from the Resident #23's account during a phone call with the bank on 12/1/21 when they told her another bank card had been used. When asked why she did not report the allegation of financial exploitation to authorities, she said she did not think the resident's case required a DHS referral because the alleged thief did not meet the criteria of a caregiver. Staff N stated she consulted with the Director of Social Services and the Administrator to make sure they agreed. She added the bank planned to return as much money as they could from the fraud investigation, but they could only go back 60 days. Staff N stated she wanted the bank to report the suspected fraud to law enforcement since they had all of the records and the specifics of the card use. When asked how much money was missing, Staff N guessed between $5,000 and $10,000 according to bank statements; someone had used Resident #23's debit card since September of 2021 without his knowledge. Staff N said she learned of the missing funds during the first week of November and they suspected the resident's acquaintance, although the always kept his debit card with him in his wallet. Staff N did not feel they had enough information or proof to notify the police at that time - they wanted the bank to do it since they had all of the financial information and could access the ATM footage. Staff N, SW reported she asked the bank several times to investigate the Resident's account starting with a bank representative in August. In an interview on 12/02/21 at 01:59 PM, the Director of Nursing (DON) stated she had not been informed facility staff suspected someone of stealing from Resident #23. She expected staff to report large amounts of missing money to the manager on duty if staff had suspicion of theft of a resident's items so the SW could initiate an investigation if they suspected someone of stealing money from a resident. The social worker would then submit the investigation to the DON or Administrator and someone in management would need to notify the police. In an interview on 12/02/21 at 03:59 PM, the Administrator stated he did not think that staff ever told him they suspected someone of stealing money from Resident # 23. The Administrator recalled Resident #23 admitted in April 2021 and the Department of Veterans Affairs (VA) invoked Power of Attorney (POA) for medical decisions only when Resident #23 admitted to the facility, although the resident remained in charge of his own money. The Administrator knew that Staff N, SW worked with DHS and Resident #23's bank regarding an application for Medicaid. The Administrator reported staff were educated, that if a resident reported a missing item, they were to report it to the nurse manager, DON, or administrator and the facility would subsequently follow reporting policies. In an interview on 12/06/21 at 1010 AM, the Administrator stated the bank reported to their fraud unit, but not to the police. The facility called police on 12/03/21 (during the survey). The police came to the facility to do an investigation. SW called DHS on 12/03/21. They are not going to investigate. The resident has control over his own finances. SW received education on policy on reporting to DHS on these types of cases. In an interview on 12/06/21 at 11:15 AM, Resident #23 stated he was in charge of his own finances and had not received a statement since he moved to the facility. The Resident knew of suspected missing funds from his account and he thought someone used an old card, although he verified he did not give anyone the pin or permission to use his money. Resident #23 said the bank suspected his friend from a previous residence and added his friend had not come to visit since he became aware of money missing from his account. The Resident wanted to believe his friend did not take any money from him, but was not sure now. The Abuse Policy/Resident Protection Plan facility policy revised 05/2021 documented staff to assess upon admission and periodically thereafter, each resident's susceptibility to maltreatment. Residents will also be evaluated for any abusive potential toward themselves, other residents and employees. Notify the Administrator and DON immediately and other officials in accordance with state law. If it appeared there was reasonable suspicion that the maltreatment may involve a crime, the Executive Director, Administrator and DON would notify the police. Any team member who had reasonable cause to believe that a resident had been the victim of dependent adult abuse/maltreatment must report suspected maltreatment/dependent adult abuse of a resident. If a family member or resident representative is possibly contributing to the potential abuse and the resident could be at risk, evaluate the situation and identify options to put into place for resident protection including notification of law enforcement and/or state agencies as indicated. It was the policy of the Facility that abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State law. Local law enforcement would be notified of any reasonable suspicion of a crime against a resident.

F657D · No harm, potential for more than minimal, isolated

Based on record review and staff interviews, the facility failed to provide the necessary provisions to ensure a resident at risk for falls received adequate supervision (Resident #7). The facility reported a census of seventy eight (78) residents. Findings included: A Minimum Data Set (MDS) with an assessment reference date of 6/1/10, documented Resident #7 required one staff to physical assist with bed mobility, transfers, walking in his/her room, toilet use and personal hygiene. The assessment revealed Resident #7's scored a 2 on his/her standing balance test. A score of 2 meant the resident required partial physical support during the test or stood but did not follow directions for the test. The MDS identified Resident #7 had impaired decision making skills along with short and long term memory deficits. The assessment identified the resident had a fall within the last thirty (30) days. The annual MDS with the assessment reference date of 8/23/10 documented Resident #7 now required two staff physical assistance for transfers. According to a physician progress notes [REDACTED]. Record review established a fall with no injury that occurred on February 24, 2010 where the facility did not provided the floor mat as describe in the following documentation: The Incident/Accident Report dated 2/24/10 revealed Resident #7 had been resting in bed, then the staff person heard the resident's alarm sounding and found him/her lying on the floor with the walker toppled over. According to the investigative worksheet, this was an isolated fall for Resident #7 and the worksheet evaluated whether any environmental factors contributed to the incident. The staff responded, "Yes, the mat by the resident's bed had not been in place. The investigation included a plan for preventing reoccurrence of the fall and staff documented, "Make sure mat is in place on floor by (the resident's) bed. " The Fall Risk assessment dated [DATE] revealed the resident had scored a nineteen (19) and had been at high risk for falling. Review of a facility Incident/Accident Report dated May 29, 2010 indicated Resident #7 had been sitting in a chair, reportedly bent over to pick something up off the floor, when s(he) fell forward hitting his/her head. The care plan documented the bed and pressure alarms were discontinued on 5/25/10. The care plan documented a fall on 5/29/10. The Care Plan documented a hand written note on 6/1/10 to continue the goals even though the resident had no serious injuries from falling. The Care Plan identified the goals were necessary to continue as Resident #7 had cognitive deficits. A Care Plan with a problem date of June 9, 2010, identified Resident #7 at risk for injury related to a fall history. The same care plan included a goal for the resident to remain free from serious injury and instructed staff to place mats on the floor next to the resident's bed. The care plan also identified the following interventions: assist resident to wear non-skid footwear; use 1(staff) for assistance with transfers; and use 1 (staff) for assistance with ambulation and keep the resident ' s bed in the low position with brakes on. According to the facility Director of Nursing (DON) and review of a Care Plan with a goal date of June 9, 2009, the instructions for staff to place a mat beside the resident's bed had been initiated on June 9, 2009. Record review established a fall with injury that occurred on July 8, 2010 where the facility did not provided the floor mat as describe in the following documentation and interview: The Incident/Accident Report dated July 8, 2010, revealed Resident #7 had been in bed taking a nap and staff had been in a room nearby when they heard a noise coming from the resident ' s room. Staff entered the resident's room and found him/her lying on the floor. The nursing staff assessed the resident and noticed his/her range of motion (ROM) different, and described it as "altered". The resident complained of pelvic pain during the assessment. The investigation worksheet identified the resident had a history of [REDACTED]. The staff did not document whether the floor mat(s) had been in place at the time of the resident's fall. Review of Nurse's Notes dated July 8, 2010 at 2:50 P.M., documented the resident had laid down after lunch, a CNA (Certified Nurse Aid) had been in a room next to the resident's room and heard a noise. The CNA found the resident laying on the floor on his/her right side saying "help me", reaching for his/her groin area and complaining of pain. The note further indicated the resident could not bear weight after the fall and required the assistance of three (3) staff members to transfer to the bed. Review of a radiology report dated July 8, 2010 revealed Resident # 7 had suffered a right pelvic fracture related to the fall as described above. During interview on September 2, 2010 at 8:17 A.M., Staff J confirmed he/she had been in Resident #7's room immediately after the resident had been found on the floor on July 8, 2010. Staff J stated the resident had been found next to his/her bed and the floor mat had not been on the floor near the bed. Staff J stated he/she had seen the resident's floor mat at the end of the resident's bed leaning against the bed. On 7/8/10, the resident's care plan documented a hand written dictation to "provide low bed with mat. " After the fall, the nurse's notes dated July 8, 2010 at 11 P.M., documented the resident did not attempt to get out of bed during the shift and had the floor mat in place. According to the nurse's notes dated 7/10/10 documented the resident's bed was at the low position, and the floor pad (mat) in place. The nurse's notes dated 7/9/10 documented Resident #7 complained of pain but unable to state where or the level of pain. Review of Physician order [REDACTED]. The nursing staff requested a physical therapy (PT) evaluation dated 7/9/10 if the resident sustained [REDACTED]. The Medication Record for the month of July, 2010 documented staff should administer Vicodin for severe pain (only). The record identified Resident #7 received pain medication on the following dates: July 8, 9, 10, 11, 13, 14, 16 and 19. The resident indicated s(he) had pain on his/her right hip, right pelvis pain, and or pain all over. Further review of Resident # 7's Medication Record for July 2010 indicated staff had been required to monitor the resident's pain level four (4) times a day. (A facility pain assessment tool instructed staff to monitor the resident's pain based on a scale of 1-10 with 10 being the highest intensity of pain). The same Medication Record indicated the resident had no pain up until the resident's fall on July 8, 2010. After the resident's fall on July 8, 2010 the Medication Record indicated the resident had rated his/her pain ranging from a two (2) to a nine (9), for the dates July 8, 2010 - July 20, 2010. Review of a physician progress notes [REDACTED]." During interview on September 2, 2010 at 9:50 A.M., the DON stated he/she expected the resident's floor mat to be next to his/her bed when he/she had been in bed as directed on the resident's Care Plan. The DON stated she felt the resident fell out of his/her bed but could not be certain. The DON confirmed the resident's fall on 7/8/10 was not witnessed by anyone. During another interview with the DON on 9/2/10 at 1:40 P.M., she stated nurses are to make the round(s) to make sure interventions are in-place. The DON stated she had advised the nurses they need to know what's going on and there's no documentation of this. During interview on September 2, 2010 at 11:52 A.M., Staff II stated Resident #7 needed to have a floor mat on the floor next to his/her bed at all times when in bed. During interview on September 2, 2010 at 12:00 P.M., Staff A5 stated Resident #7 required the use of a floor mat on the floor next to his/her bed when in bed. During telephone interview on September 2, 2010 at 12:07 P.M. Staff A25 stated Resident # 7 required the use of a floor mat on the floor next to the bed when in bed. Based on observation and staff interview the facility failed to secure hazardous chemicals from cognitively impaired residents. The facility reported a census of seventy eight residents. findings included: During Environmental Tour of the facility on September 2, 2010 at 9:27 a.m. the right lower cupboard on the right side of the entry in the second floor southeast dining room held the following: one 17 ounce spray can of TMA Stainless Steel Cleaner; 2 ten ounce spray cans of Sheila Shine stainless steel polish; one eight ounce can of WD-40 lubricant. The left lower cupboard held one 17 ounce spray can of TMA stainless steel cleaner and one gallon jug of Ecolab Lime Away. All the above listed items directed to "Keep Out of the Reach of Children". Staff provided a list of seven residents with cognitive impairment who were independently mobile either by means of ambulation or in a wheel chair.

← Back to the Wesley on Grand record

Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction