Wesleyan Health Care Center

In the surveyor’s words

From the most serious findings on record at Wesleyan Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Nov 1, 2021

  Based on interview and record review, the facility failed to protect cognitively impaired residents from a resident with sexually aggressive behaviors in 2 of 2 encounters (Resident B, Resident C, and Resident D). This deficient practice resulted in a non consensual sexual act with a cognitively impaired resident. The immediate jeopardy began on [DATE] when Resident B was observed to be touching and rubbing a female residents leg (Resident D) while attempting to place her hand on his private area. The Administrator was notified of the immediate jeopardy on [DATE] at 12:42 p.m. Findings include: Review of a behavior sheet, dated [DATE] at 1:01 p.m., indicated Resident B was observed to be touching and rubbing a female resident's leg while attempting to place her hand on his private area. […]

• Actual harm, isolatedF689Dec 17, 2024

  Based on interview and record review, the facility failed to ensure services for bed mobility were provided with two staff members present to a dependent resident who required total assistance of two staff for bed mobility for 1 of 3 residents reviewed for falls. (Resident 99) This deficient practice resulted in Resident 99 falling from the bed and sustaining a fracture left knee joint. Findings include: Resident 99's clinical record was reviewed on 12/13/14 at 11:29 a.m. Diagnoses included, but were not limited to, quadriplegia (a severe medical condition characterized by the partial or total loss of function in all four limbs and the torso), left elbow contracture, left shoulder contracture, left wrist contracture, left hand contracture, right shoulder contracture, right wrist… […]

• Actual harm, isolatedF690May 6, 2024

  Based on observation, interview, and record review, the facility failed to ensure urinary catheter outputs were monitored and documented for 3 of 3 residents reviewed for urinary catheters (Residents D, H, and J), resulting in Resident D being transferred to the hospital with a large amount of urine retained from a blocked urinary catheter. Findings include: 1. Resident D's clinical record was reviewed on 5/2/24 at 1:22 p.m. Diagnoses included, but were not limited to, neuromuscular dysfunction of bladder, unspecified focal traumatic brain injury (TBI) with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, and need for assistance with personal care. […]

• Actual harm, isolatedF689Aug 11, 2023

  Based on record review and interview, the facility failed to ensure supervision during dining for 1 of 4 residents reviewed for accidents. (Resident B) This deficient practice resulted in the resident choking and requiring placement on a ventilator at the hospital. Findings include: Review of a facility self-reportable to the State Agency, dated 8/5/23 at 7:01 p.m., indicated Resident B had an episode of choking at dinner time. The resident had a diet of pureed, and mechanical soft upon request, and was currently receiving speech therapy. During dinner, a table mate gave the resident a sandwich, which the resident began eating, and staff noticed the resident began choking. The nurse was notified and the resident required the Heimlich maneuver and suctioning to be done in the dining room. […]

• Actual harm, isolatedF689Aug 20, 2021

  Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent a resident from falling resulting in fractures for 1 of 8 residents reviewed for falls (Resident 67), failed to ensure residents had call lights in reach during a random observation (Resident 85) and failed to follow care plan interventions for a dependent resident to prevent falls for 1 of 8 residents reviewed for falls (Resident 102). Findings include: A. During an observation, on 8/18/21 at 9:54 a.m., Resident 67 was lying in bed hollering out, a floor mat was on the floor beside her bed, and the other side of the bed was against the wall. The resident's clinical record was reviewed on 8/17/21 at 1:57 p.m. […]