Wesley Place on Honeysuckle

In the surveyor’s words

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

• Immediate jeopardy, isolatedF656Mar 23, 2024

  Based on interviews, review of Resident Identifier (RI) #195's medical records, review of a third-party complaint, and the facility's policies titled, Care Plans, Comprehensive Person-Centered and Perineal Care, the facility failed to ensure care planned interventions were developed to instruct staff how to safely position RI #195 in bed during incontinent care; including how many staff members were required to safely provide incontinent care for RI #195. The facility further failed to ensure RI #195's care planned interventions for bilateral half side rails for safety during care was implemented by Certified Nursing Assistance (CNA) #6. […]

• Immediate jeopardy, isolatedF689Mar 23, 2024

  Based on interviews, record review, the facility's investigative file, hospital record review, the facility policy titled, and review of a third-party complaint, the facility failed to ensure Resident Identifier (RI) #195's upper side rails were up for safety during the provision of incontinent care; and failed to ensure two staff assisted to reposition RI #195 during the incontinent care. On 09/14/2023, Certified Nursing Assistant (CNA) #6 was providing incontinent care to RI #195 without a second staff to assist. CNA #6 repositioned RI #195 to the left side, turned around to obtain a wipe, and when she turned back around RI #195 was sliding from the left side of the bed. RI #195 fell head and upper body first from the bed to the floor. […]

• No harm, potential for more than minimal, patternF582Sep 16, 2021

  Based on interviews, review of Resident Identifier (RI) #1 and RI #2's billing statements, the facility's Resident Handbook, and a complaint received by the State Survey Agency, the facility failed to refund any and all refunds due to the resident and/or the resident's representative within 30 days from the date of discharge from the facility. This deficient practice affected two of three sampled residents reviewed for refund of personal funds. Findings include: RI #1 was admitted to the facility on [DATE] and discharged home on 5/23/21. On 8/13/21 the State Survey Agency received a complaint which alleged that RI #1's representative had not received a refund of the money paid to the facility for the resident's room and board for the month of May 2021. […]

• No harm, potential for more than minimal, isolatedF641Mar 23, 2024

  Based on interviews, record review, the Long-Term Care Resident Assessment Instrument 3.0 Manual, and the facility policy titled Care Plans, Comprehensive Person-Centered, the facility failed to ensure Resident Identifier (RI) #96's Quarterly Minimum Data Set (MDS) assessment dated [DATE], was accurately coded to reflect Resident Identifier (RI) #96's behavioral symptoms. This deficient practice affected one of 51 sampled residents whose MDS was reviewed. Findings include: RI #96 was admitted on [DATE] and diagnoses that included Dementia, Moderate with Mood Disturbance, Alzheimer's Disease Late Onset. A review of facility policy titled Comprehensive Assessments with a Revised date of 03/2022 documented, Policy Interpretation and Implementation 1. […]

• No harm, potential for more than minimal, isolatedF655Mar 23, 2024

  Based on observations, interviews, record review and review of a facility policy titled, Care Plans -Baseline, the facility failed to ensure Resident Identifier (RI) #196's and RI #198's baseline care plans addressed the use of their Continuous Positive Airway Pressure (CPAP) machines. This deficient practice affected RI #196 and RI #198, two of six sampled residents whose baseline care plans were reviewed. Findings include: A review of a facility policy titled, Care Plans-Baseline, with a revised date of 03/2022, revealed the following: . Policy Interpretation and Implementation 1. […]