The Wolfe Living Center At Summit Ridge

Based on record review and interview, the facility failed to ensure a resident's assessment was accurately coded for 1 (#1) of 3 sampled residents reviewed for accuracy of resident assessments. The administrator identified 41 residents resided in the facility. Findings: A policy titled MDS 3.0 Completion, dated 10/01/24, read in part, Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. A Quarterly MDS, ARD of 04/18/25, showed Resident #1 had diagnoses of Alzheimer's, dementia, and severely impaired cognition. The assessment showed section E0900 (Section of the MDS for wandering) was coded as 0 for wandering in the seven day look-back period. A Progress note, dated 04/18/25 at 6:00 a.m., showed Resident #1 had wandered/paced three times that shift. An Elopement Risk Assessment, dated 04/18/25 at 2:49 p.m., showed Resident #1 was at risk for elopement. The assessment showed the resident wandered aimlessly or was non-goal-directed. On 04/20/25 at 3:03 p.m., ADON #1 reviewed Resident #1's MDS…

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 facilty failed to review and revise the care plan for 1 (#1) of 3 sampled residents whose care plans were reviewed for elopement. The administrator identified 41 residents resided in the facility. Findings: A policy titled Comprehensive Care Plans, dated 03/24/25, read in part, Resident specific interventions that reflect the residents' needs.The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. An incident report for elopement for Resident #1, dated 04/15/25, read in part, Call received from maintenance staff the resident was in the back of the building ambulating across the parking lot. Maintenance staff stayed with resident until nursing staff reached [them] and assisted [them] back into the facility without incident. A head to toe assessment was performed with no noted injuries or distress. Video was reviewed, resident was shown leaving through the ambulance door on East Wing without door alarm sounding.INTERVENTIONS: 15 minute visual checks 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.

Based on record review and interview, the facility failed to ensure a resident's POA was included in their clinical record for 1 (#13) of 16 sampled residents reviewed for advance directives. The administrator identified 38 residents resided in the facility. Findings: Resident #13 had diagnoses which included cognitive communication deficit and atrial fibrillation. Resident #13's Advance Directives Acknowledgement form, dated 08/21/23, read in part, I do have an Advance Directive/ Living Will/ Durable Power of Attorney for medical or health care decisions. Resident #13's clinical record did not contain a copy of their POA. A Residents' Rights Regarding Treatment and Advance Directives policy, dated 03/24/25, read in part, It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate advance directives .Advance Directive is a written instruction, such as a living will or durable power of attorney .On admission, the facility will determine if the resident has executed an advance…

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 ensure advance beneficiary notices were provided for 2 (#140 and #141) of 3 sampled residents who were reviewed for beneficiary notices. The Beneficiary Notice - Residents discharged within the Last Six Months form, showed 12 residents who were discharged to home with skilled days remaining in the last six months. Findings: A facility policy titled Wolfe Living Center-Advanced Beneficiary Notices, dated 02/17/22, read in part, It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage .If services are being terminated and the beneficiary wants to continue receiving care that is no longer considered medically reasonable and necessary, the facility shall issue an ABN prior to furnishing non-covered care. 1. The Beneficiary Notice - Resident Discharge Within the Last Six Months form, showed Resident # 140 was discharged from skilled services, had skilled days remaining, and discharged home. Resident #140's EHR…

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 implement their abuse policy by not: a. conducting a complete and thorough investigation; b. establishing coordination with the QAPI program; c. reporting to the OSDH within 2 hours of the allegation of abuse; and d. assess the residents for any sign of injury for 2 (#1 and #23) of 2 sampled residents reviewed for abuse. The administrator identified 38 residents resided in the facility. Findings: A facility policy titled Abuse, Neglect, and Exploitation, dated 01/01/22, read in part, The facility will develop an implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of resident and misappropriation of resident property; b. Established policies and procedures to investigate any such allegations; and c. Include training for new existing staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, reporting procedures, and dementia management and resident…

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 ensure an allegation of abuse was reported immediately to the state agency, but no later than two hours after the allegation was made for 1 (#1) of 2 sampled residents reviewed for abuse. The administrator identified 38 residents resided in the facility. Findings: A facility policy titled Abuse, Neglect, and Exploitation, dated 01/01/22, read in part, 1. Reporting of all alleged violations to Administrator, state agency, adult protective services, and to all other required agencies within Specified timeframe: a. Immediately, but not later than two hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury. Resident #1 was admitted to the facility on [DATE] with diagnoses which included cerebral palsy, dysphagia, and cognitive communication deficit. Resident #1's annual assessment, dated 12/08/24, showed Resident #1's BIMS score was 03 and they were dependent on staff for showers and baths.…

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 thoroughly investigate an allegation of abuse for 1 (#1) of 2 sampled residents reviewed for abuse and neglect. The administrator identified 38 residents resided in the facility. Findings: A facility policy titled Abuse, Neglect, and Exploitation, dated 01/01/22, read in part, The facility will develop an implement written policies and procedures that: . 4. Identifying and interviewing, all involve persons, including the alleged victim, alleged, perpetrator, witnesses, and others who might have knowledge of the allegation . 6. Providing complete and thorough documentation of the investigation. Resident #1 was admitted to the facility on [DATE] with diagnoses which included cerebral palsy, dysphagia, and cognitive communication deficit. Resident #1's annual assessment, dated 12/08/24, showed, Resident #1's BIMS score was 03 and they were dependent for showers and baths. An OSDH form 283, combined initial and final report, dated 08/26/24, showed an…

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, record review and interview the facility failed to ensure residents received their baths/showers as scheduled for 1 (#25) of 1 sampled resident reviewed for activities of daily living. The administrator identified 38 residents resided in the facility. Findings: On 03/25/25 at 10:44 a.m., Resident #25 was observed with a medium length beard, hair combed, dressed in a long sleeve shirt, with long pants, and no odors present. A Bathing a Resident policy, dated 01/2022, read in part, It is the practice of this facility to assist residents with bathing to maintain proper hygiene and help prevent skin issues. Resident #25 had diagnoses which included stage 4 chronic kidney disease and bilateral primary osteoarthritis of knee. An admission resident assessment, dated 03/12/25, showed Resident #25's cognition was intact (BIMS 15), and they required supervision or touching assistance for the task of shower/bathe self. The assessment showed it was very important to Resident #25 to choose between a tub bath, shower, bed bath, or sponge bath. An undated shower schedule…

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, record review and interview, the facility failed to ensure wound care was provided as ordered for 1 (#4) of 2 sampled residents reviewed for non pressure wounds. ADON #1 identified six residents with non pressure wounds resided in the facility. Findings: On 03/26/25 at 1:30 p.m., Resident #4 was observed in the horse shoe activity. The resident was observed to have ace wrap dressings to their bilateral lower legs and shoes and socks to their bilateral feet. A clean dressing change policy, dated 01/2022, read in part, It is the policy of this facility to provide wound care in a manner to decrease potential for infection .Physician's orders will specify type of dressing and frequency of changes. Resident #4 had diagnoses which included a full thickness venous ulcer. Resident #4's current wound care order, dated 03/05/25 with a start date of 03/12/25, showed a wound care order for the left posterior lower leg venous wound: cleanse with wound cleanser, pat dry with gauze, apply collagen powder, super absorbent pad, wrap with four layer wrap once weekly and prn…

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 ensure side effect of monitoring was in place for a resident who was prescribed anticoagulant therapy for 1 (#22) of 5 residents sampled for unnecessary medication. The ADON identified three residents were prescribed anticoagulant medication. Findings: An undated facility policy titled Medication Monitoring, read in part, This facility takes a collaborative, systematic approach to medication management, including the monitoring of medication's for efficacy and adverse consequences .'Adverse Consequence' refers to unwanted, unintended, or dangerous effects that a drug may have, such as impairment or decline in an individual mental or physical condition or functional or psychosocial status. Resident #22 was admitted on [DATE] with diagnoses which included schizoaffective bi-polar type and cognitive communication deficit. Resident #22's annual assessment, dated 01/17/24, showed their BIMS score was 15 and they were prescribed an anticoagulant 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.

Based on observation, record review, and interview, the facility failed to utilize a gait belt when assisting a resident in a geriatric chair for one (#2) of one sampled resident observed being positioned during the lunch meal service. The Administrator identified 39 residents resided in the facility. Findings: A Use of Gait Belt policy, dated 01/2022, read in part, .It is the policy of this facility to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety .Each nursing department employee will be given a gait belt during orientation .All employees will receive education on the proper use of gait belt during orientation and annually . A Turning and Repositioning policy, dated 01/22, read in part, .Repositioning techniques in bed .To minimize friction and shear, use sheets or lift equipment to avoid pulling or dragging . Resident #2 had diagnoses which included dementia and cognitive communication deficit. A quarterly assessment, dated 10/27/23, documented Resident #2 had severe cognitive impairment, and they required…

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 and interview, it was determined the facility failed to ensure the removal of expired medications and supplies from the medication storage room and medication cart. This had the potential to affect all 39 residents who resided in the facility. Findings: On 10/12/22 at 9:45 a.m., the medication room was observed. Expired medications and supplies were found in the facility's medication room refrigerator and medication storage room for the following. 1. 9- Bisacodyl suppositories with an expiration date of 09/2022. 2. 7- Hepatitis B vaccines with an expiration date of 03/01/22. 3. 1- Box [NAME] 20cc syringes with an expiration date of 11/01/21. 4. 14- BD Safety-Lok 3ml syringes with an expiration date of 06/29/21. 5. 10- [NAME] Prevent Syringes with Safety Hypodermic Needle 3cc/23gauge with an expiration date of 03/31/22. 6. 2- Entra-Flo Gastrostomy Feeding Tubes with an expiration date of 08/06/22. 7. 2- Boxes adhesive remover wipes with an expiration date of 02/16/21. 8. 1- Box Inter-dry…

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.