Wesley Glen Health Services Corp

Based on observation, resident and staff interview, and policy review, the facility failed to ensure food was served at a palliative and safe food temperature. This had the potential to affect all 51 residents in the facility who the facility identified to receive food from the kitchen. Findings include: Interview on 04/21/25 at 1:35 P.M. with Resident #37 stated the food was not hot enough when it comes to his room. Interview on 04/23/25 at 2:19 P.M. with Registered Nurse (RN) #321 stated Resident #37 has complained about the temperature of his food. Interview on 04/23/25 at 2:41 P.M. with Certified Nursing Assistant (CNA) #227 stated she receives complaints from residents about the temperature of food. CNA #227 stated she always warms up Resident #37's food. Interview on 04/23/25 at 4:37 P.M. with Dining Services Director (DSD) #276 stated hot food should be served to residents at a minimum of 135 degrees Fahrenheit (F) and cold food should be served to residents at 41 degrees F or below. Observation of the second floor tray line was made on 04/23/25 at 5:02 P.M. with Universal…

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 policy reviews, the facility did not maintain a clean sanitary kitchen, store food in a safe manner, and serve foods to the residents in a sanitary manner. This had the potential to affect all 51 residents in the facility who the facility identified receive food from the kitchen. Findings include: 1. Observation and interview on 04/21/25 at 10:53 A.M. with Dining Services Director (DSD) #276 of the second floor kitchen verified the interior ambient temperature of the sandwich cooler was 52 degrees Fahrenheit (F) . Observation and interview on 04/21/25 at 11:01 A.M. with DSD #276 and Dining Operations Manager (DOM) #303 confirmed the food located within the sandwich cooler on the second floor was above the appropriate food holding temperature. The sliced tomatoes were 47 degrees F and the hard boiled eggs were 46 degree F, sliced turkey 50 degrees F, chicken salad 46 degrees F, sliced American cheese was 46 degrees F and skim milk was 61 degrees F. Observation and interview on 04/22/25 at 4:46 P.M. with DSD #276 of the second floor…

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, staff interview, medical record review, review of Centers for Disease Control and Prevention (CDC) guidance, and facility policy review, the facility failed to appropriately disinfect equipment during a wound care treatment and ensure the resident's wound did not touch a dirty surface during the wound treatment. The facility also failed to ensure a resident who received medications intravenously and had a wound had enhanced barrier precautions (EBP) in place. This affected one (Resident #13) of one resident reviewed for wound care treatment and one (Resident #155) of one resident reviewed for EBP. The facility identified eight residents (#13, #28, #33, #103, #104, #105, #108 and #155) who received wound dressing changes on the second floor. The facility census was 51. Findings include: 1. Review of Resident #13's medical record revealed she was admitted on [DATE] with diagnoses including diabetes mellitus type II, sternal fracture, multiple rib fractures and moderate protein malnutrition.…

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, and resident and staff interview, the facility failed to maintain the patient care equipment in safe operating condition. This had the potential to affect 27 residents who resided on the second floor and utilized the second floor spa. The facility census was 51. Findings include: Interview on 04/21/25 at 5:04 P.M. with Resident #103 revealed the grab bar in the spa room next to the toilet was shaky and coming off the wall. Observation and interview on 04/24/25 at 9:37 A.M. with Maintenance Technician (MT) #444 verified the second floor spa room grab bar next to the toilet was very loose. MT #444 stated he doesn't know how to fix it as they have tried all the fasteners they have. Interview on 04/24/25 at 1:49 P.M. with Maintenance Director #450 confirmed the grab bar was broken. Maintenance Director #450 stated if he was aware of an issue, it was fixed the same day or the next day as they were on call seven days a week.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure the resident's had care plans in place for pain management, enhanced barrier precautions, and an acute infection. This affected two (Residents #10 and #31) of 18 residents reviewed for care plans. The facility census was 51. Findings include: 1. Record review revealed Resident #10 was admitted to the facility on [DATE]. Diagnoses included wedge compression fracture of second lumbar vertebra. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had a significant cognitive impairment. Review of Resident #10 current physician orders revealed the following medications order for low back pain: diclofenac sodium external gel one percent and Tylenol extra strength 500 milligrams (mg). Review of Resident #10's care plan revealed there was no care plan in place for pain management/treatment. Interview with Director of Nursing (DON) on 04/24/25 at 3:31 P.M. confirmed Resident #10 did not have a pain care plan.…

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, medical record review, and staff interview, the facility failed to ensure fall interventions were in place for a resident who was at a high risk for falls. This affected one (Resident #40) of two residents reviewed for falls. The facility census was 51. Findings include: Review of Resident #40's medical record revealed she was admitted on [DATE]. Diagnoses included diabetes mellitus, myocardial infarction, depression, frequent falls, and acute ischemic cerebrovascular accident. Review of the comprehensive care plan dated 11/03/24 revealed Resident #40 was at risk for falls. An intervention was added on 11/07/24 to apply a perimeter mattress to the resident's bed. Review of the fall risk assessments, dated 11/07/24 and 03/03/25 revealed Resident #40 was at a high risk for falls. Review of Certified Nursing Aide (CNA) [NAME], dated 04/23/25 revealed a perimeter mattress to bed was listed under the safety section. Observation on 04/23/25 at 7:30 A.M. revealed Resident #40 was sleeping in a low…

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, observation, resident and staff interview, and policy review, the facility failed to honor the resident's food requests or preferences. This affected two (Resident #24 and #103) of three residents reviewed for food preferences. The facility census was 51. Findings include: 1. Review of the medical record for Resident #24 revealed an admission date of 05/28/21. Diagnoses included intellectual disabilities and type II diabetes mellitus. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 had severe cognitive impairment and required partial/moderate assistance for eating, Review of the care plan revealed Resident #24 was at risk for altered nutrition status due to a history of a feeding tube that has been removed and a mechanically altered diet. Resident #24 liked small individual bowls for her food. An intervention included foods in individual bowls. Observation on 04/23/25 at 6:34 P.M. revealed Resident #24's dinner revealed her food 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the facility's policy, staff interviews, review of online resources at Center for Medicaid and Medicare Services (CMS) and Centers for Disease Control and Prevention (CDC), and record review, the facility failed to maintain infection control protocols and wear the appropriate Personal Protective Equipment (PPE) in resident rooms that were in quarantine to prevent the potential spread of COVID-19. This affected one (Residents #160) of two residents reviewed for transmission based precautions (TBP). This had the potential to affect all 45 residents residing in the facility. Findings include: Review of the medical record for Resident #160 revealed an admission date of 09/02/22. Diagnoses included gangrene, kidney failure atrial fibrillation, and heart disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #160 was cognitively intact and required extensive assistance of one staff member for mobility. Review of the physician's orders dated…

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 staff interview, review of the facility's Self-Reported Incidents (SRI), review of the facility's policy, and medical record review, the facility failed to timely report an allegation of sexual abuse to the State Survey Agency, the Ohio Department of Health. This affected one (Resident #162) of three residents reviewed for abuse. The facility census was 45. Findings include: Review of the Resident #162's medical record revealed an admission date of 01/09/21. Resident #162 was admitted with diagnoses of Parkinson's disease, dementia, and encephalopathy. Review of facility's SRI Control Number 218191 revealed the was submitted on 02/22/22 at 10:52 A.M. The SRI was related Resident #162 reporting an allegation of sexual abuse against STNA #66. Review of the facility's investigation related to SRI control number 218191, revealed at the end of day shift, Resident #162 was crying and reported to an state tested nursing aide (STNA) that a man had been trying to rape her in her room. She identified the man as STNA #66 . STNA #66 was sent home immediately. Interview on 09/08/22 at…

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 medical record review, review of the facility's Self-Reported Incidents (SRI), staff interview and review of the facility's policy, the facility failed to complete a thorough investigation regarding a resident's allegation of sexual abuse. This affected one (Resident #162) of three residents reviewed for abuse. The facility census was 45. Findings include: Review of the Resident #162's medical record revealed an admission date of 01/09/21. Resident #162 was admitted with diagnoses of Parkinson's disease, dementia, and encephalopathy. Review of facility's SRI Control Number 218191 revealed the was submitted on 02/22/22 at 10:52 A.M. The SRI involved Resident #162 reporting an allegation of sexual abuse against State Tested Nursing Aide (STNA) #66. On 02/21/22 at the end of day shift, Resident #162 was crying and reported to an STNA a man had been trying to rape her in her room. Review of facility's investigation of SRI Control Number 218191 revealed the facility interviewed four alert and oriented residents who resided on Resident #165's unit. The facility did not assess…

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 resident, family, and staff interviews, review of the facility's policy, and record review, the facility failed to ensure medications were administered as physician ordered. This affected two (Residents #149 and #159) of five residents reviewed for medication. The facility census was 45. Findings include 1. Review of the medical record for Resident #159 revealed an admission date of 09/04/22 at 5:54 P.M. Diagnoses included back pain, anxiety, and surgical stabilization of rib fractures for ribs five, six, seven, eight, and nine. Review of the hospital discharge referral documents dated 08/28/22 revealed Resident #159 had a historical diagnosis of back pain with multiple acute rib fractures requiring surgical revision and a diagnosis of anxiety. Resident was on several pain medications during her hospitalization and was weaning off intravenous (IV) Dilaudid (treats moderate to severe pain) and transitioning to oral Oxycodone (treats moderate to severe pain). Review of the hospital Discharge summary dated…

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 medical record review, staff interview, and policy review, the facility failed to administer a pneumonia vaccine to a resident. This affected one (Resident #8) of five residents reviewed for immunizations. The facility census was 45. Findings include: Medical record review for Resident #8 revealed an admission date of 09/29/20. Diagnoses included chronic respiratory failure, tropical spastic paraplegia, and cerebral infarction. Further record review for Resident #8 revealed a consent for the pneumonia vaccine dated 09/29/20 by Resident #8's Power of Attorney (POA). Review of Resident #8's physician orders revealed there was no order to administer the pneumonia vaccine. Review of immunizations in Resident #8's electronic medical record revealed it was silent for documentation of the pneumonia vaccine. Interview on 09/12/22 at 12:44 P.M. with the Director of Nursing (DON) revealed the facility offers the pneumonia vaccine to residents. The facility reviews the residents' records periodically for pneumonia vaccine status and offers the vaccine if indicated. Subsequent…

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.