Wexner Heritage House

In the surveyor’s words

From the most serious findings on record at Wexner Heritage House, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 16, 2021

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of a facility Self-Reported Incident (SRI), review of a facility investigation, review of the facility Medical Appointment and Transportation policy and procedure and interview with facility staff and Bystander #910 the facility failed to provide adequate supervision to Resident #24, who was assessed to have cognitive impairment, delusional disorder and was dependent on staff activities of daily living, following an appointment outside the facility on [DATE] at 1:00 P.M. Resident #24 did not timely return to the facility and his whereabouts were unknown for an extended period of time. […]

• Actual harm, isolatedF690Dec 29, 2025

  Based on medical record review, hospital document review, interview, and facility policy and procedure review, the facility failed to ensure laboratory testing and timely follow-up was completed to diagnose and treat a urinary tract infection (UTI).Actual harm occurred beginning on 12/10/25 when Resident #94 exhibited signs/symptoms of a UTI (burning) without evidence of adequate intervention. On 12/11/25 a plan for a urine culture (due to complaints of burning on urination and elevated temperature) was noted; however, the facility failed to send the urine specimen to the laboratory. On 12/16/25 (five days later) the facility recognized the urinalysis was not completed, and a urine specimen was obtained for testing. […]

• Actual harm, isolatedF686Oct 23, 2025

  Based on closed record review, hospital record review, policy review and interview the facility failed to implement a comprehensive, resident centered plan for the prevention and treatment of pressure ulcers.Actual Harm occurred on 09/03/25 when Resident #86, who had resided in the facility less than 30 days, was cognitively impaired and required staff assistance with activities of daily living, was assessed to have an unstageable pressure ulcer to the sacrum with necrosis requiring debridement. […]

• Actual harm, isolatedF686Jun 10, 2025

  Based on observation, record review, review of wound notes, facility policy review and interview, the facility failed to assess, monitor, and implement a comprehensive and individualized prevention program to prevent the development of avoidable pressure ulcers and failed to ensure adequate interventions were in place to prevent new pressure injuries for Resident #61. Additionally, the facility failed to comprehensively assess, monitor and implement a treatment for Resident #80's unstageable (full-thickness skin and muscle loss, with slough or eschar obstructing the wound bed making it impossible to determine the true depth of the ulcer.) pressure ulcer on admission to the facility for more than two days. […]

• No harm, potential for more than minimal, widespreadF812Dec 29, 2025

  Based on observation, staff interview, and facility policy, the facility failed to ensure the dishwasher and three compartment sink was in a working order. Additionally, the facility failed to maintain the kitchen in a sanitary manner and store and prepare foods in a sanitary manner. This had the potential to affect 83 out of 85 residents residing in the facility with two residents on a nothing by mouth (NPO) diet. the facility census was 85.During observation of the kitchen area on 12/15/25 at approximately 9:40 A.M. with Regional Dietary Manager (RDM) #601, upon entering the kitchen and performing hand hygiene, the surveyor observed the paper towel dispenser at the handwashing sink was broken and nonfunctional. RDM #601 confirmed at 9:40 A.M. […]