Wesley Pines Retirement Community

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF580Jan 30, 2026

  Based on observations, record review, resident, Nurse Practitioner, and staff interviews the facility failed to notify the Physician when nursing staff were not following a physician order for daily administration of one capsule of Linzess (a medication for long-lasting or chronic constipation from unknown reasons) and were administering 3 capsules of Linzess twice weekly per the resident's request for 1 of 1 resident reviewed (Resident #19). Findings included: Resident #19 was admitted to the facility on [DATE]. Diagnoses included chronic idiopathic (unknown reason) constipation, and gastroparesis (food and liquid remaining in body for prolonged period of time). The Minimum Data Set quarterly assessment dated [DATE] revealed Resident #19 was cognitively intact. […]

• No harm, potential for more than minimal, patternF658Jan 30, 2026

  Based on observations, record review, and staff, resident, Consulting Pharmacist and Nurse Practitioner interviews, the facility failed to follow a physician's order as written to administer Linzess (a medication for chronic constipation) daily for 1 of 1 resident reviewed (Resident #19). The nursing staff were dispensing the medication into a bottle on Resident #19's bedside table labeled with a different medication name and then Resident #19 was taking the 3 capsules of the medication on Tuesdays and Fridays. (Resident #19 was not assessed to be able to self-administer medications). Findings included: Resident #19 was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, patternF761Jan 30, 2026

  Based on observations, record review, and staff and resident interviews, the facility failed to store medications in a secured medication cart when medications were observed stored in a resident's room and two of the medications were expired for 1 of 1 resident with medications observed at the bedside (Resident #19). In addition, the facility failed to date an opened insulin pen and discard an expired insulin pen for 1 of 2 medication carts observed for medication storage (Lantana Cart). Findings included: a). Resident #19 was admitted to the facility on [DATE]. The Minimum Data Set, dated [DATE] revealed Resident #19 was cognitively intact. […]

• No harm, potential for more than minimal, patternF684Apr 14, 2022

  Based on record review and staff interviews, the facility failed to administer the antibiotic [MEDICATION(S)] per the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: Resident #42 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Admission MDS (Minimum Data Set) assessment dated [DATE] documented Resident #42 had intact cognition. She had one venous/arterial ulcer on admission. Review of the Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF885Apr 14, 2022

  Based on record review and staff interview the facility failed to inform resident representatives (RP) and families by 5:00 PM the next calendar day following the occurrence of sixteen confirmed staff and eleven confirmed resident COVID-19 infections from 01/05/22 through 02/03/22 for thirteen instances the facility did not contact family/RP of sixteen staff and eleven residents reviewed for COVID-19 reporting. Findings included: Review of the facility COVID-19 testing log revealed 2-staff tested positive on 01/05/22 and 01/06/22. An interview with the Administrator on 04/11/22 at 11:00 AM revealed the 2-staff who tested positive for COVID-19 on 01/05/22 and 01/06/22 were notified of positive COVID-19 status via facility-rapid test the same day. […]