W Frank Wells Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the kitchen food service observations, staff interviews, facility document review and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness with the potential to affect all of the residents in the facility. The facility failed to ensure that the dietary staff used proper procedures for hand hygiene, disposable glove use, food storage and proper sanitation practices in the kitchen and for the two ice machines located in the main dining room and the restorative dining area. Safe food handling and good sanitation is important in health care settings serving nursing home residents due to the risk of serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: During the initial tour of the facility kitchen on 12/02/24 at 9:22 AM an observation of the reach in freezer…

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 facility document review, staff interview and facility policy and procedure review the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) committee composed of required members when the Medical Director failed to attend QAPI meetings on a monthly or quarterly basis from July 2024 through November 2024. The facility failed to provide evidence of communication of the program data to the Medical Director for his review and receive meaningful feedback from him on possible quality deficiencies and trends that might have required more frequent monitoring and may have resulted in negative health outcomes for the residents of the facility. The findings include: A review of the QAPI meeting minutes for the months of June 2024 through November 2024 revealed the facility QAPI committee met on 06/14/2024, 07/09/2024, 08/20/2024, 10/03/2024, 10/31/2024 and 11/06/2024. The meeting attendance was recorded and the Medical Director attended only the June meeting by phone (Copies obtained). During an interview on 12/04/2024 at 10:30 AM with the Administrator…

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 and interviews, the facility failed to address missing wall trim mid-wall, leaving sharp and splintered wood exposed in three (rooms [ROOM NUMBER]) of 16 rooms observed on the east hall, from a total of 36 rooms in the facility. Sharp and splintered wood in resident rooms could result in resident injury with pain and possible infection. The findings include: During room observations, starting on December 2, 2024, at 11:50 a.m., the following was observed: a. In room [ROOM NUMBER], Bed A was missing the wall trim above the bed, mid-wall. Bed B was missing wall-trim above the bed, with partial trim still in place and jagged edges exposed. (Photographic evidence obtained) b. In room [ROOM NUMBER], Bed A was missing the wall trim at the headboard of the bed. [NAME] beams from the base of the wall, running up mid-wall were still in place with unfinished wood exposed. Bed B was missing the wall trim, mid-wall above the bed. (Photographic evidence obtained) c. In room [ROOM NUMBER], Bed A was…

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, record review, and facility policy and procedure review, the facility failed to provide oxygen at the prescribed flow rate for one (Resident #7) of one resident reviewed for oxygen therapy from a total survey sample of 23 residents. The findings include: On 12/02/24 at 11:39 AM, the resident was observed with oxygen infusing at 1 Liter per minute via nasal cannula from the e-cylinder hanging on back of the resident's wheelchair. On 12/04/24 at 3:32 PM, the resident was observed with oxygen infusing at 1 Liter per minute via nasal cannula from the e-cylinder hanging on the back of the resident's wheelchair. (Photographic evidence obtained) A review of Resident #7's medical record revealed an admission date of 7/3/24 and diagnoses including, but not limited to, encephalopathy, dependence on supplemental oxygen, and generalized anxiety disorder. A review of the resident's active physician orders revealed the following: Oxygen at 2 liters per minute via nasal cannula continuously (ordered 7/4/24) Change oxygen tubing and humidifier weekly (ordered…

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, record review, and facility policy and procedure review, the facility failed to honor food preferences for one (Resident #2) of one resident reviewed for food preferences from a total survey sample of 23 residents. The findings include: On 12/02/24 at 10:07 AM, Resident #2 stated, I have already told them what foods I don't like and what foods I can't have because of my GERD but they still send it. On 12/04/24 at 8:54 AM, Resident #2 was observed in bed with her breakfast tray sitting on the bedside table. Registered Nurse (RN) I was observed administering the resident's medication. Another staff member entered the room to collect the resident's breakfast tray and was asked to remove the food tray cover so the percentage of food consumption could be observed. The surveyor and RN I observed bacon and sausage gravy (on top of an open biscuit) remaining on the plate. The tray card was reviewed with RN I and it indicated that the resident disliked .bacon, sausage . A review of 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 a review of the facility's policy and staff interview, the facility failed to maintain documentation to demonstrate evidence of its ongoing Quality Assurance Performance Improvement (QAPI) program. The findings include: During the Quality Assurance Performance Improvement (QAPI) review with the Administrator and the Director of Nursing, conducted on 1/26/23 at 11:30 a.m., there was no current documentation to demonstrate evidence that the facility had an active QAPI program. On 1/26/23 at 11:50 a.m., an interview was conducted with the Administrator and the Director of Nursing. Both confirmed they were unable to provide documentation of any recent ongoing QAPI initiatives. The facility provided a sheet that read 2018 QAPI Plan. (Copy provided) The facility had no specific policy related to maintaining documentation for their QAPI program. .

Based on policy review and staff interviews, the facility failed to effectively maintain a system to identify, collect and use data and information from all departments, including, but not limited to the facility assessment, adverse event monitoring, and feedback from direct care staff, including how such information would be used to develop and monitor performance indicators. The findings include: During the Quality Assurance Performance Improvement review with the Administrator and the Director of Nursing, conducted on 1/26/23, there was no evidence that the facility had any active Performance Improvement Projects. On 1/26/23 at 11:50 a.m., an interview was conducted with the Administrator and the Director of Nursing. They both confirmed that there was no evidence that the facility had any Performance Improvement Projects at the time of the survey. A review of the facility's policy titled QAPI Plan, with an effective date of 11/2017, read as follows: Page 1, #6, stated a program of operation with quality concerns will be described and the choosing of performance improvement…

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 obtain physician's orders and a diagnosis for a urinary catheter for one (Resident #12) of two residents sampled for a review of urinary catheters, from a total of 19 residents in the sample. The findings include: A review of the facility's Resident Matrix, printed on 1/23/23, revealed that Resident #12 had an indwelling urinary catheter. A record review was conducted for Resident #12, revealing an admission date of 10/26/22. The resident's diagnoses included cardiomyopathy, interstitial pulmonary disease, heart failure, hypertension, and atherosclerotic heart disease. A review of the resident's active Physician's Order Sheets for January 2023, revealed no diagnosis or physician's orders for a urinary catheter or catheter care. (Photographic evidence obtained) A review of the resident's care plan, dated 11/15/22, revealed that Resident #12 was admitted with an indwelling urinary catheter. He received extensive assistance to meet his toileting needs with interventions that included administration of medications as ordered;…

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, policy review, and staff interview, the facility failed to follow appropriate infection control guidelines for urinary catheter bags for two (Residents #2 and #12) of seven residents with urinary catheters, from a total of 19 residents sampled. The findings include: 1. On 1/23/23 at 10:22 a.m., Resident #2 was observed self-propelling in his wheelchair down the hallway on the west wing near the nursing station. His urinary catheter bag was dragging on the floor under his wheelchair. (Photographic evidence obtained) On 1/23/23 at 1:46 p.m., during an interview with Resident #2 in his room, he stated his urinary catheter got in his way. At this time, the catheter bag observed to be connected to the underside of his wheelchair. The bag and tubing were touching the floor. Also, as the resident moved back and forth in his wheelchair, his catheter bag dragged on the floor. (Photographic evidence obtained) On 1/24/23 at 10:35 a.m., Resident #2 was observed in the hallway of the west wing, self-propelling toward the nursing station in his wheelchair. His urinary…

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.