A.g. Rhodes Home Wesley Woods

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Medication Administration Policy, the facility failed to assess for the ability to self-administer medications prior to leaving medications at the bedside for one of 44 sampled residents (R) (R50). The deficient practice had the potential to allow access to medications otherwise not prescribed by a physician to other residents. Findings include: Review of the facility's policy titled Medication Administration policy revised December 2023 indicated the following: Policy: Medications are administered by licensed nurses, or other care partner who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Review of the medical record for R50 revealed diagnoses including but not limited to encephalopathy, unspecified, transient cerebral ischemic attack, unspecified, difficulty in…

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, staff interviews, and review of the facility policy titled, Preventive Maintenance, the facility failed to ensure the residents' living area was safe, clean, comfortable, and homelike in three rooms (room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) on two of four halls (300 Hall and 400 Hall). Specifically, residents' rooms contained damaged sheetrock walls with holes, scuffed/chipped paint, and a dirty personal fan that had the potential to affect patient comfort and safety. Findings Include: Review of the facility's undated policy titled Safe and Homelike Environment revised 7/20/2024 revealed under Intent Preventive Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Observation on 9/9/2025 at 8:30 am in rooms [ROOM NUMBERS] revealed, scuffed/ chipped paint and a hole in the wall. Observation on 9/9/2025 at 8:10 am in room [ROOM NUMBER] revealed a…

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, staff interviews, and review of the facility policy titled, Comprehensive Care Plans, the facility failed to complete/update care plans for two of 44 sampled residents (R) (R40 and R3). Specifically, R3 had orders for oxygen therapy and oxygen was not on the care plan. Also, the facility failed to complete a care plan for R40 related to hearing loss and communication interventions. The deficient practice had the potential to lead to negative health outcomes and unmet care needs.Findings include: Review of facility policy titled, Comprehensive Care Plan revised on 6/26/2023 states under Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The policy explanation and compliance guidelines revealed: The care planning process will include an assessment of the resident's…

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, resident and staff interviews, record review, and review of the facility policy titled, Accident and Supervision, the facility failed to ensure the residents' environment remained free of potential accident hazards for three of 44 sampled residents (R) (R131, R122 and R48). Findings include: Review of the facility policy titled Accidents and Supervision revised on 6/26/2023 states under intent: The elder environment will remain free of accident hazards as is possible. Each elder will receive adequate supervision and assistive devices to reduce the risks of accidents. This includes identifying hazard(s) and risk(s), evaluating and analyzing hazard(s) and risks, implementing interventions to reduce hazard(s) and risk(s), and monitoring for effectiveness and modifying interventions when necessary. The policy explanation and guideline states: The community shall establish and utilize a systematic approach to address elder risk and environmental hazards to minimize the likelihood of accidents.…

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, staff interviews, record review, and review of the facility policy titled, Oxygen Therapy, the facility failed to administer oxygen (O2) at the correct ordered setting for one of 21 residents (R) (R3) receiving O2 therapy. This deficient practice had the potential to place R3 at risk for hypoxia (low O2 levels) which could have led to adverse clinical outcomes.Findings include:Review of facility's policy titled Oxygen Therapy revised May 2024 indicated the following: Policy Explanation and Compliance Guidelines: Oxygen is administered under the orders of a physician, except in cases of an emergency. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: The type of oxygen delivery system, When to administer, such as continuous or intermittent and/or when to discontinue, Equipment setting for the prescribed flow rates, Monitoring of SpO2 (oxygen saturation) levels and/or vital signs as…

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, staff interviews, and review of the facility policies, the facility failed to document receive dates on food items in the dry storage area; failed to ensure dietary staff washed hands after entering the kitchen and between touching dirty/clean dishes; failed to discard food items past the best by date; and failed to ensure dietary staff properly sanitized dishware to prevent cross contamination. There were 134 residents consuming an oral diet. Findings include: 1. Review of the policy titled Production, Purchasing, Storage - Food and Supply Storage revised 1/2024, revealed foods past the use by, sell by, best by, best by, or enjoy by date should be discarded. Date and rotate items; first in, first out and discard food past the use by or expiration date. Observation on 4/5/2024 at 9:15 am, the dry storage area revealed a shelf containing four, 32-ounce containers of Dijon mustard, two one-gallon containers of mayonnaise, one gallon container of balsamic dressing, one gallon container of BBQ sauce, and an eight-pound container of salsa all with no receive date.…

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, staff interviews, and review of the policy titled PASRR Program Policy, the facility failed to submit an application for Level II Preadmission Screening and Resident Review (PASRR) for evaluation and determination of specialized services for two of three residents (R) R65, and R116 reviewed for PASRR. R65 was admitted to the facility with diagnoses of post-traumatic stress disorder (PTSD), psychotic disturbance, mood disturbance, anxiety, and major depressive disorder. R116 was admitted with diagnoses of PTSD, schizophrenia, depression, and anxiety disorder. Findings include: Review of the policy titled PASRR Program Policy revised 6/8/2023, revealed the policy states the facility coordinates assessments with the preadmission screening and resident review (PASRR) program to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance…

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, review of facility recipes, and staff interviews, the facility failed to ensure that dietary staff followed recipes for preparing puree food items to avoid compromising the nutritive value and flavor. This affected 14 residents receiving a pureed diet. Findings include: Review of the undated recipe titled P. Chicken BBQ Quarter revealed the ingredients listed included with amount for serving of 20: Chicken BBQ Quarter 5 pounds, Chicken Broth 2 1/8 cup, and thickener 1 1/3 cup. Review of the undated recipe titled P. [NAME] White revealed the ingredients listed included amount for 48 servings: prepared white rice, vegetable broth, and thickener. During the preparation of puree food items on 4/6/2024 at 11:35 am, Dietary [NAME] FF was observed preparing puree BBQ chicken. He placed an unmeasured amount of steamed diced chicken into a standard blender bowl, then added an unmeasured amount of chicken broth and began to puree. Dietary [NAME] FF stopped the blender and added an unmeasured amount of BBQ sauce, two different times, and continued the puree process.…

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 observation, record review, interviews, and policy review titled, Medication Administration: General Guidelines, the facility failed to assess two residents (R) R#35 and R#79 for the ability to safely self-administer medications, before leaving mediations at bedside for residents to self-administer. Findings include: Review of the facility policy titled, Medication Administration: General Guidelines, revised 4/10/19 revealed procedure 3. Patients/residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. Procedure 4. Medications are administered at the time they are prepared. Medications are not pre-poured/pre-set/pre-crushed. Only one patient/resident's medications are prepared and administered at a time. 1. Observation on 5/17/22 at 10:36 a.m. during initial tour/screening with R#35, surveyor observed a bottle of saline nasal spray on R#35's bedside table. R#35 informed surveyor…

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, policy review, interviews, and Rule 410-10-.02 Standards of Practice for Licensed Practical Nurses, the facility failed to maintain professional nursing standards of quality as evidenced by one of four Licensed Practical Nurse's (LPN) observed during facility medication administration task by presetting medications; also failed to practice infection control guidelines during medication administration and during point of care testing for two of two nurses observed. Findings include: 1. Review of the facility policy titled, Medication Administration: General Guidelines, revised 4/10/19, revealed policy statement as medications are administered as prescribed, in accordance with the good nursing principles and practices. Procedure 4. Medications are administered at the time they are prepared. Medications are not pre-poured/pre-set/pre-crushed. 10. Medications are administered within 60 minutes before or after scheduled time, except for medications ordered to be taken with food and before or after meals, which are administered precisely as ordered. Unless…

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 staff interview, the facility failed to ensure the medication error rate was less than five percent (5%). A total number of 26 medication opportunities were observed. There were three errors for one of five residents (R), R#12, by one of three nurses observed during medication pass, for a medication error rate of 11.54%. Findings include: Observation of medication administration on 5/18/22 at 9:04 a.m., with Licensed Practical Nurse (LPN) CC revealed she pulled a clear medicine cup containing multiple medications from the medication cart for R#12. LPN CC stated that she pre-set the medications earlier on her shift, to save time. Surveyor asked LPN CC to count the number of pills in the cup and she confirmed that was all the medications resident was to receive at that time. She then placed all the medications from the clear plastic cup in the pill crush sleeve and crushed the medications together and opened the three capsules. She combined all the crushed medications in a plastic cup with applesauce. She then prepared the liquid medications…

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, staff interviews, and review of facility policies, the facility failed to maintain an effective Infection Control Program (ICP) to prevent the spread of infections by not disinfecting a multi-use blood glucometer (a device used to test blood sugar levels) between residents for one of two nurses observed; also failed to ensure nursing staff performed hand hygiene during medication pass for one of four nurses observed. Findings Include: 1. Review of the facility policy titled Glucometer Policy Glucometer Cleaning and Disinfecting, revised 4/28/21 policy statement revealed if one device must be used to monitor several residents, it must be cleaned and disinfected after every use following the manufactures' instructions to prevent carryover of blood and infectious agents. Procedure 1. Clean and disinfect glucose meter before and after each patient use. 4. Clean and disinfect meter by using approved Germicidal and Disinfectant Wipes. Observation on 5/18/22 at 8:13 a.m. with Licensed Practical Nurse (LPN) AA, was observed to remove a glucometer from the medication…

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.