Susanna Wesley Health Center

Based on observations, interviews and record reviews the facility failed to protect residents' information on the third floor as evidenced by, an observation of a computer screen unattended with residents' information visible and easily accessible. There were 118 residents residing in the facility at the time of survey. The findings included: On 6/12/25 at 10:28 AM while ambulating along the third floor hallway, the observed a the screen of an unattended computer with residents' information visible. Interview on 6/12/25 at 10:33 AM Staff J, Registered Nurse (RN) was asked about protecting resident information and protocol for the computer screen when unattended. Staff , RN stated: The cart is to be locked, and the computer is screen is to be closed when I walk away. To protect the privacy of all residents. Sometimes I minimize the screen and if the cart is moved it opens up again. Interview on 6/12/25 at 1:33 PM, the Director of Nursing revealed nurses were instructed on locking the computer screen when leaving the medication cart and not to minimize screen with resident information…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and record review the facility failed to code a Minimum data set that accurately reflects resident's status for one (Resident #275) out of one sampled resident as evidenced by the MDS not coded for indwelling urinary catheter, despite Resident #275 having an indwelling urinary catheter since admission. There were seven residents with indwelling urinary catheter at the time of the survey. The findings included: On 6/09/25 at 10:13 AM, Resident #275 was observed seated in the activities area with an indwelling urinary catheter in place. On 6/11/25 at 4:29 PM, Resident #275 was observed in bed watching tv, an indwelling urinary catheter was in place, inside a dignity bag. Review of Resident 275 clinical records revealed admissions dated 4/16/25 and 5/22/25. Clinical diagnosis: Encounter for other orthopedic aftercare. Record review of a physician's order sheet revealed an order dated: 5/22/23 for Indwelling urinary catheter for Diagnosis Obstructive Uropathy Review of an admission Minimum Data Set (MDS) reference dated 5/28/25 indicate in Section C for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review and interviews, the facility failed to revise a tube feeding care plan for one (Resident #97) out of one sampled resident as evidenced by the care plan interventions included abdominal binder despite no physician order for an abdominal binder. There were nine residents with tube feedings at the time of survey. The findings included: On 6/09/25 at 9:53 AM Resident #97 was observed in bed with the head of bed elevated and a tube feeding in progress. Record review of Resident #97's demographic sheet revealed an admission date of 2/17/25 clinical diagnosis including Dysphagia following cerebral infarction and Encounter for attention to gastrostomy. Record review of a Scheduled 5-day Minimum Data Set (MDS) reference dated 2/3/25 revealed Resident #97 had a Brief Interview of Mental Status score s 00, indicating severe cognitive impairment, was dependent on staff for Activities of Daily Living, and had a feeding tube. Record review of a care plan started on: 2/18/25, last reviewed/revised: 6/02/25 revealed Resident #97 has the potential for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide supervision to prevent accident hazards for one (Resident #275) out of one resident sampled, as evidenced by a fire lighter in a transparent bag observed next to Resident #275 while resident was seated in the activities area where other residents were gathered. There were 118 residents residing in the facility at the time of survey. The findings included: On 6/09/25 at 10:13 AM Resident # 275 was observed seated in a wheelchair in The activities room amongst other residents. Surveyor observed a fire lighter inside a transparent bag next to Resident #275 (photographic evidence). The surveyor asked Resident #275 what the lighter is used for and Resident # 275 stated: My business. The Registered Nurse Manager was immediately notified and retrieved the lighter from Resident #275 and stated: [Resident #275] is not allowed to have this lighter and is not a smoker. Interview on 6/09/25 at 10:15 AM, Staff K, the assigned Certified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and record review, the facility failed to demonstrate effective action plans were implemented to correct identified quality deficiencies in the problem area related to prevent repeated deficient practice for F641- Accuracy of assessment. As evidenced by inaccurate MDS coding. The findings included: Review of the facility's survey history revealed, during a recertification survey with exit dated 02/15/ 2024, F641- Accuracy of assessment was cited related to the facility's failure to accurately code the Minimum Data Set (MDS) assessment for two out of four residents reviewed for assessments. During this survey with an exit dated 06/12/2025, repeated deficient practice was identified for F641- Accuracy of assessment, related to failure to code indwelling urinary catheter under section H for Resident # 275. During an interview on 06/12/2025, at 2:30 PM, the Director of Nursing and Administrator revealed Quality Assurance and Performance Improvement (QAPI)/Quality Assessment and Assurance (QAA) committee meets monthly, and the last meeting was held on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility's staff failed to implement infection prevention control policies and procedures to ensure a sanitary environment and failed to provide proper perineal and catheter care to help prevent Urinary Tract Infections (UTI); as evidenced two clear plastic bags containing trash on the third-floor hallway and during perineal care staff did not change gloves and wash hands when transitioning from a contaminated area to a clean area and did not change water in the basin between cleaning steps. There were 116 residents residing in the facility at the time of the survey. The findings included: On 06/09/2025 08:46 AM, during observational tour, of the third floor two clear plastic bags containing trash was observed on the third-floor hallway next to a residents' room. (photographic evidence). Interview on 06/12/2025 at 01:38 PM, Staff M, Certified Nursing Assistant (CNA) regarding the trash and soiled supplies on the hallway. Staff M revealed the soiled linen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure medically needed social services were provided for one resident (Resident #4) out of three residents reviewed. The resident was charged $100.00 for someone to accompany him each time he went out to an appointment. There were 117 residents residing in the facility at the time of the survey. The findings included: Review of the facility's Transportation to an Appointment Policy and Procedure (no written date); Policy Statement-Our facility will assist residents in arranging transportation to/from appointments when necessary; Policy Interpretation and Implementation-1) Should it become necessary to transport a resident to an appointment, when necessary, outside the facility, the Social Service Designee or Charge Nurse shall notify the resident's representative and inform them of the appointment; 2) The resident's representative will be responsible for transporting the resident to his or her appointment; 3) Should it become necessary for the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to ensure the Third Floor Pantry refrigerator used exclusively for the resident's was maintained in a sanitary manner as evidenced by opened undated milk carton observed. This has the potential to affect fifty-five residents out of fifty-seven residents who eat orally residing on the Third floor. The findings included: Observation of the Third Floor Nourishment Pantry on 2/14/2024 at 7:33 AM revealed a pint carton of 2% reduced milk was opened and not dated. Photographic evidence submitted. Observation and interview with Staff C, Registered Nurse (RN), Nursing Supervisor on 2/14/2024 at 7:34 AM. She confirmed the milk carton was open and not dated. She stated, I forgot to check the refrigerator. They said they just opened the milk. Interview with the Dietary Supervisor on 2/14/2024 at 7:58 AM. She revealed that nursing is responsible for making sure the pantry refrigerators are in order and are contained properly. Interview with the Registered Dietitian on 2/14/2024 at 8:56 AM revealed that once a milk carton is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interview, and record review the facility failed to provide a safe environment for residents on the second floor, as evidenced one out of one Biohazard room observed on the facility's second floor door was kept unlocked. This has the potential to affect the 58 residents residing on the second floor during the survey. The findings included: On 02/14/2024 at 10:15 AM The door of the Biohazard room on the second floor was not locked. On 02/14/2024 at 10:15 AM, Staff B observed entering Biohazard room by pushing the door open. The Biohazard room door unlocked while staff inside. On 02/14/2024 at 10:20 AM; One staff member observed pushing the door of the Biohazard room open and entering. The Biohazard room door was unlocked while staff inside. On 02/14/2024 at 10:25 AM, Staff B, Certified Nursing Assistant stated there is a key to open the door; I didn't use it because the door was open. On 02/14/2024 at 10:26 AM, Staff C, Registered Nurse Supervisor stated: the Biohazard room door should always be locked to prevent residents from entering the room and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, records review and interview, the facility failed to promote dignity while dining for two Residents (#21 and #62) out of twenty-six sampled residents, as evidenced by observations of staff standing over Resident #21 and Resident #62 while assisting to eat. The findings included: On 02/12/2024 at 8:05 AM in room [ROOM NUMBER] bed b, Staff G, Certified Nursing Assistant (CNA) observed standing while assisting Resident #21 with breakfast. Record review of Resident #21's demographic face sheet revealed the resident was admitted on [DATE] and readmitted on [DATE] with diagnosis that included Diabetes mellitus and Severe Protein-Calorie Malnutrition. Record review of Discharge Return Anticipated Minimum Data Set (MDS) dated [DATE], Section C for cognitive patterns revealed a Brief Interview Mental Status (BIMS) score of undetermined out of a scale of 0-15, that indicated severe cognitive impairment. Section K for swallowing/nutrition status revealed resident #21 received a mechanically altered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to electronically transmit the Discharge- Return Non-Anticipated Minimum Data Set (MDS) to Centers of Medicare and Medicaid (CMS) within 14 days for one (Resident # 10) out of two residents whose assessments were investigated. Resident #10 who was discharged to the community but the MDS was not transmitted. There were 120 residents residing in the facility at the time of survey. The findings included: Record review of the clinical records for Resident # 10 revealed the resident was admitted to the facility on [DATE] and was discharged home on [DATE]. Review of the Discharge Return Non-Anticipated MDS Section A Identification Information dated 10/01/2023 revealed the resident was discharged to the community (home). The Discharge Return Non-Anticipated MDS dated [DATE] was not transmitted within 14 days after completion. During an interview with the MDS Coordinator on 02/14/24 at 01:19 PM. She reported that the assessment was completed but not transmitted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for two (Resident #117 and Resident #44) out of four residents reviewed for residents' assessments. There were 120 residents residing in the facility at the time of the survey. The findings include: 1) In a record review for Resident #117, the resident was admitted to the facility on [DATE] and was discharged home on [DATE]. Record review of medical diagnosis include heart failure, muscle/ wasting atrophy (gradual decline) of left/ right upper arms and left/right lower leg. Review of physician orders revealed Resident #117 was to be discharged home on 1/12/2024 with home health with a Registered Nurse, physical therapist, and occupational therapist with a wheelchair, walker, and commode. Review of the Care plan that started on 10/04/2023 revealed that Resident #117 overall goal was established during the assessment process and expects to be discharged home with daughter. Review of progress notes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, records review, and interviews. The facility failed to ensure medications were securely stored, as evidenced by fourteen loose pills and two half pills were found on one out of two medication carts checked. There were 120 residents residing in the facility at the time of the survey. The findings included: On 02/13/2024 at 02:48 PM, during observation and interview with Staff A, LPN (Licensed Practical Nurse) on the third-floor medication cart two. Fourteen loose pills and two half pills were found. (photographic evidence). Staff A, LPN was asked: What is the facility's policy for checking and cleaning medications carts? Staff A LPN stated, The 11-7 shift cleans the cart and on weekends. I check the medications, check for expired meds, and that medications are up to date. I cleaned the cart. When I find loose pills. We dispose of them in the drug buster. In an Interview on 02/13/24 at 03:13 PM, the Nursing Supervisor was asked: What is the facility's policy for checking and cleaning medication carts? The nursing Supervisor stated: The Pharmacist was here…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview the facility failed to ensure the arbitration agreements presented to three residents (Resident number 70, Resident number 84, and Resident number 220) out of three residents reviewed informed residents or their representatives of the nature and implications of any proposed binding arbitration agreement, to inform their decision on whether or not to enter into such agreements. There were 120 residents residing in the facility at the time of the survey. The findings included: Record review of the Binding Arbitration Agreements on facility letterhead documented the following: 1) The facility offers arbitration agreements; 2) The facility asks residents or their representatives to enter into an arbitration agreement, 3) The facility had residents who entered a binding agreement on or after 9/16/2019 and 4) The Admissions Coordinator is responsible for the binding arbitration agreements. Review of the facility Voluntary Arbitration Agreement documented the following: Resident number 70 signed and dated on 6/02/2020, Resident number 84 signed and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.