Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wesleyan Health Care Center during CMS and state inspections, most recent first.
Surveyors identified multiple failures in sanitary food handling and storage, including a CNA who adjusted two residents in wheelchairs and then unwrapped and handled a piece of bread with bare hands without performing hand hygiene. Dietary staff were observed touching their face and hair, biting fingernails, and then handling food-contact surfaces and food items, including touching the inside of bowls while plating food, using bare fingers to arrange chicken on plates, placing the food-contact side of plastic bowl covers against clothing, and using fingers to remove potato skin. In dry storage, several dented cans with damage on end seams remained in regular stock instead of being removed per policy. A resident reported observing staff touch their face and arms during meal service without subsequent handwashing, and facility policies required avoidance of bare-hand contact with food, proper handwashing, and removal of cans with dents over seams.
Surveyors found that the facility failed to provide necessary nail care for two residents who were dependent on staff for ADLs. One resident with dementia and epilepsy was repeatedly observed with long, dirty, chipped fingernails despite receiving multiple showers, and another resident with cerebral palsy and profound intellectual disabilities had dried debris under most fingernails while requiring total assistance for personal care. Staff interviews showed inconsistent practices and understanding about when and how CNAs and nurses should perform and document nail care, and facility policy only stated that nail care would be provided "as needed," leading to unaddressed nail hygiene needs.
A resident with hypertension and coronary artery disease had an order for losartan 50 mg daily with instructions to hold the dose if systolic blood pressure (SBP) was below 110, and a care plan that called for BP monitoring and administration of antihypertensives as ordered. Review of MARs over two months showed multiple instances where the resident’s SBP was documented below 110, yet losartan was still administered and not held. QMAs and an LPN reported that their practice was to check BP before giving antihypertensives and to hold medications with parameters when readings were outside the ordered range, and one QMA acknowledged she should have held the medication when SBP was below 110. The DON stated she expected staff to hold BP medications when parameters were not met, and the facility’s policy required licensed staff to consult and follow physician orders and parameters, which did not occur in this case.
A resident with dementia, depression, bradycardia, and AFib, who required partial to maximal assistance for transfers, ambulation, and toileting, experienced numerous falls over a short period, including falls with injury and a major injury. Despite being care planned as high risk for falls due to impaired judgment, memory loss, history of falls, narcotic analgesics, and psychotropic use, the resident was repeatedly found on the floor in her room, bathroom, and near doorways after attempting unassisted transfers or ambulation. Facility documentation consistently identified root causes such as self-transfers and ambulating without assistance in the context of severe cognitive impairment and poor safety awareness, while staff interviews acknowledged frequent falls and ongoing self-initiated mobility. Observations and records show that the resident continued to be in situations where she could move without effective supervision, leading to repeated accidents in violation of the facility’s obligation to prevent avoidable accidents.
A resident with cerebral palsy, dysphagia, and a PEG feeding tube had physician orders and care plans requiring Enhanced Barrier Precautions (EBP) due to the feeding tube. An EBP magnet and PPE were present at the room, but during observed PEG site care, a Unit Manager performed high-contact device care using gloves only and did not don a gown, despite scant tan drainage noted at the site. The DON and IP gave inconsistent interpretations of when gowns were required, and the IP stated she would not have used a gown in the same situation. The facility’s EBP policy, however, identified residents with feeding tubes as requiring EBP and specified gown and glove use for high-contact activities, including feeding tube care.
A resident with quadriplegia and contractures fell from bed and fractured her knee after a CNA attempted to provide care without the required two-person assistance. Despite the care plan indicating the need for two staff members for bed mobility, the CNA proceeded alone, leading to the resident's fall. Interviews revealed that staff were aware of the two-person requirement, but documentation inconsistencies showed the resident was often recorded as needing only one-person assistance.
A resident's call light was not within reach, violating the facility's policy to accommodate resident needs. The resident, with conditions like hemiplegia and dementia, was observed without access to the call light in both a wheelchair and bed. An LPN confirmed the oversight, noting it may have been misplaced during a bedsheet change.
A resident with multiple health conditions experienced a deficiency in their living environment due to a failure to repair a hole in the wall of their room. The hole, which allowed cold air to enter, was temporarily plugged with a blue glove by an x-ray technician. Despite the resident's requests for repair, no work orders were submitted, and the facility lacked a policy for room maintenance. The administrator and maintenance director were unaware of the issue, and the facility did not use blue gloves, indicating the glove was not from the facility.
A resident with severe cognitive impairment was observed multiple times without being shaved, despite requiring assistance with personal hygiene. Interviews with CNAs revealed inconsistencies in shaving routines, and the DON acknowledged the lack of documentation for refusals or behaviors. The facility's policy required personal hygiene twice daily, which was not followed for this resident.
A resident with dementia lost their lower denture and the facility failed to arrange timely dental appointments, resulting in a prolonged period without the necessary dental appliance. Despite initial efforts with Company A, the replacement denture was delayed and never arrived. The family obtained a new denture from Company C, but it went missing again, and by the following year, the resident still did not have a replacement. The facility's policy required timely referrals for lost dentures, but this was not followed, and staff interviews revealed a lack of awareness and documentation regarding the resident's dental needs.
The facility failed to follow proper infection prevention and control strategies for two residents in COVID-19 isolation. A resident's room lacked a sign indicating required precautions, and staff did not use face shields as required. Another resident's caregiver incorrectly placed an N95 mask over a surgical mask. Both residents were under strict isolation orders due to positive COVID-19 tests, and the facility's policy required specific PPE use.
The facility failed to ensure urinary catheter outputs were monitored and documented for three residents, resulting in one resident being hospitalized with a blocked catheter and urinary tract infection. Inconsistent documentation and lack of adherence to catheter care policies were observed.
The facility failed to administer insulin as ordered and scheduled for two residents. Insulin was administered late on multiple occasions, and the Director of Nursing indicated that while insulin was given on time, the nurses did not document it correctly. This deficiency relates to Complaint IN00432015.
The facility failed to supervise a resident during a nebulizer treatment as required by physician orders and facility policy. The resident, who had multiple severe respiratory conditions, was found unattended with the nebulizer machine in operation. Staff interviews confirmed the lack of supervision, and the facility's policy emphasized the need for observation during such treatments.
Unsanitary Food Handling and Improper Storage of Dented Cans
Penalty
Summary
The deficiency involves failure to ensure food was prepared and served under safe and sanitary conditions, including improper hand hygiene and food handling during meal service. During a lunch observation, a CNA moved two male residents in their wheelchairs and then immediately handled a resident’s wrapped bread, unwrapping it and touching the bread with bare hands without performing hand hygiene in between. The CNA later acknowledged she did not perform hand hygiene and should not have touched the bread with bare hands. Additional observations during the same lunch period showed dietary staff engaging in multiple unsanitary practices: one dietary employee pulled her hairnet down below her ears and touched her cheeks while waiting for a tray, another dietary employee repeatedly touched the inside food-contact surfaces of bowls with his fingers while plating food, and the Assistant Dietary Manager used his bare fingers to arrange chicken pieces on a plate and placed the food-contact side of plastic bowl covers against his shirt to separate them. Another dietary employee bit around her fingernail and then handled the food-contact portion of plastic bowl covers without hand hygiene, and used a fork and bare fingers to remove the skin from a baked potato. The Dietary Manager later confirmed these actions were inconsistent with facility policies prohibiting bare-hand contact with food and requiring proper handwashing. The deficiency also includes failure to properly manage dented canned goods in dry storage. During a kitchen observation, surveyors found a can of sliced apples with a dent on the top seal, a can of peas and diced carrots with a dented seal, and a can of cheddar cheese with a dented bottom seal, all with recent intake dates. The Dietary Manager stated these dented cans should have been removed from regular storage and placed on an upper shelf for supplier credit, and signage was posted instructing staff what to look for regarding canned food. Facility policies in effect at the time required staff not to touch food with bare hands, to follow approved handwashing procedures, and to treat cans with dents over side or end seams as unsafe. A resident interview corroborated concerns about hygiene practices during meal service, with the resident reporting having seen staff touch or rub their face and arms without washing their hands afterward.
Failure to Provide Necessary Nail Care During ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary daily grooming assistance, specifically nail care, for residents who were unable to perform this activity of daily living themselves. For one resident with major depressive disorder, dementia, and epilepsy, surveyors repeatedly observed long, dirty, chipped, and jagged fingernails over multiple days, despite documentation that the resident had received several showers during the same period. The resident’s MDS showed moderate cognitive impairment and a need for partial/moderate assistance with personal hygiene, and the care plan indicated he required physical assistance with ADLs and bathing due to dementia and schizophrenia. Nonetheless, his nails remained untrimmed and uncleaned across several observations. Another resident with cerebral palsy, profound intellectual disabilities, aphasia, severe cognitive impairment, and functional limitations in both upper and lower extremities was observed with tan dried substance under seven of ten fingernails. Her care plans documented total assistance by two staff for a.m. and p.m. care and included interventions such as manicures during 1:1 programming. Staff interviews revealed inconsistent practices and understanding regarding nail care: CNAs and nursing staff variously stated that nail care was done on shower days, on an as-needed basis, or only when residents requested it, and that nail care was not documented. The DON and facility policy indicated nail care was to be provided as needed and checked on shower days, but the observed condition of the two residents’ fingernails and the lack of documentation showed that necessary nail care was not consistently provided.
Failure to Follow BP Medication Hold Parameters for Antihypertensive Therapy
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for blood pressure medication parameters for one resident. The resident had diagnoses of essential hypertension and atherosclerotic heart disease of a native coronary artery without angina pectoris, and an order for losartan potassium 50 mg daily with instructions to hold the dose if the systolic blood pressure (SBP) was less than 110. The resident’s care plan for hypertension indicated goals for blood pressure management and interventions that included taking blood pressures as ordered, monitoring for pattern changes, and administering antihypertensive medications as ordered. Review of the medication administration record (MAR) for December showed multiple dates on which the resident’s SBP was below 110 (including readings such as 109/50, 101/52, 108/64, 109/79, and 103/68), yet the losartan was still administered and not held as ordered. Review of the MAR for January showed additional dates on which the resident’s SBP was below 110 (including readings such as 109/52, 108/73, 106/52, 108/66, 108/62, 105/46, and 107/55), and again the losartan was administered instead of being held per the physician’s parameters. Interviews with QMAs and an LPN indicated that staff were aware that blood pressure should be checked prior to administering antihypertensive medications and that medications with parameters should be held and the nurse notified if readings were outside the ordered range. One QMA, upon reviewing the MAR, acknowledged she should have held the medication when the SBP was below 110. The DON stated she expected staff to hold blood pressure medications when parameters were not met. The facility’s policy on following physician orders/parameters required licensed healthcare providers to consult and follow physician orders prior to administering medications or performing procedures, which was not followed in this case.
Failure to Provide Adequate Supervision for Cognitively Impaired Resident With Recurrent Falls
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent repeated falls for a severely cognitively impaired resident. The resident had diagnoses including dementia, major depressive disorder, bradycardia, and atrial fibrillation, and required partial to maximal staff assistance with transfers, ambulation, toileting, and hygiene. MDS assessments documented severe cognitive impairment, disorganized thinking, inattention, poor safety awareness, frequent incontinence, and shortness of breath with exertion. Over time, the resident experienced multiple falls, including falls with injuries and a major injury, despite being identified as at risk for falls related to impaired judgment, memory loss, history of falls, narcotic analgesics, and psychotropic medications. From late December through mid-January, the resident had a series of falls in her room, bathroom, and common areas, often while attempting to transfer or ambulate without assistance. She was repeatedly found on the floor beside her bed, in the bathroom, near her recliner, or in doorways, frequently after attempting self-transfers or ambulating alone. Documentation consistently identified root causes such as transferring or ambulating without assistance, losing balance, and sliding from bed, with contributing factors of dementia, severe cognitive impairment, poor safety awareness, and a history of multiple recent falls. The record also notes that the resident sometimes removed her shoes, wore only socks, or manipulated and removed chair alarms, and that she frequently refused to use her wheelchair when going to the bathroom. Despite the resident’s ongoing pattern of falls and her severe cognitive impairment, the facility’s approach relied heavily on intermittent checks, signage, and environmental measures while the resident continued to self-transfer and ambulate unassisted. Staff and leadership interviews acknowledged that the resident had fallen many times in a short period, that some falls were attributed to maladaptive behaviors and possibly bradycardia, and that she continued to try to care for herself and get up on her own. Staff reported trying to keep her in common areas when awake and to keep her room door open to observe her, but observations showed that at times the resident was in bed with the door closed. The cumulative documentation shows repeated falls, including a minimally displaced radial head fracture of the right elbow, occurring in the context of severe cognitive impairment and ongoing self-initiated transfers and ambulation without consistent, effective supervision to prevent these accidents. The care plan identified the resident as at risk for falls and referenced her fracture from a fall, with interventions such as scheduled toileting, use of an anti-roll back device on the wheelchair, encouraging her to stay in common areas while up, non-slip footwear, and assisting her to areas of increased supervision when restless. However, the clinical record and narrative notes describe continued falls under similar circumstances—unassisted transfers, ambulation without help, and attempts to reach the bathroom or bed independently—indicating that the resident’s needs for supervision were not effectively met. Interviews with CNAs and nursing leadership further confirm that, despite awareness of her frequent falls and behaviors, the resident was still often in situations where she could and did attempt to move without assistance, leading to repeated accidents. Throughout this period, the resident’s pattern of behavior, cognitive status, and physical limitations remained consistent, and the facility’s own fall investigations repeatedly cited the same root causes and contributing factors. The facility’s policy states that it will provide an environment free from accident hazards and implement supervision and assistive devices consistent with residents’ needs to prevent avoidable accidents. In this case, the documented series of falls, including those resulting in injury and a major injury, occurred while the resident continued to self-transfer and ambulate without adequate, effective supervision, constituting the failure cited in the deficiency.
Failure to Follow Enhanced Barrier Precautions During PEG Tube Site Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident with a gastrostomy tube. The resident had diagnoses including cerebral palsy, dysphagia, and gastrostomy status, and received continuous enteral feeding via a PEG tube, with orders for EBP in place. Care plans documented that the resident required EBP due to the gastrostomy tube and that staff were to follow EBP during care and minimize infection risk related to the tube site. During an observation, an EBP magnet was posted outside the resident’s room, and PPE (a yellow isolation gown and gloves) was available inside the room. The Unit Manager prepared to perform PEG site care, performed hand hygiene, and wore gloves, but did not don an isolation gown. She cleansed the PEG insertion site using soapy washcloths, working from the insertion site outward and using different edges of the washcloth, then rinsed and dried the area. A scant amount of tan drainage was observed on the washcloth during cleansing. Throughout this high-contact device care activity, the Unit Manager did not wear a gown despite the facility’s EBP policy identifying feeding tube care as a high-contact resident care activity requiring gown and glove use. In interviews, the Unit Manager stated she believed gowns were only needed when dealing with the tube feeding itself or if the PEG site was red, infected, inflamed, had drainage, or if splattering might occur, and that gloves alone were sufficient for personal care. The DON initially indicated that EBP, including gown use, was required for personal care such as PEG site care and that the PEG site was the reason for the resident’s EBP status, but later acknowledged conflicting information received from the Infection Preventionist and then confirmed that a gown should have been worn. The Infection Preventionist reported conducting EBP rounding and education but stated she did not believe a gown was needed for this PEG site care because the GI tract was not sterile, there was no chance of splash, no prolonged contact, and the PEG site was old with no drainage observed, and indicated she would have done the same as the Unit Manager. The facility’s written EBP policy, however, specified that residents with feeding tubes require EBP and that PPE (gown and gloves) is necessary when performing high-contact care activities, including device care such as feeding tubes, for the duration of the resident’s stay or until the device is discontinued.
Failure to Provide Adequate Assistance Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision and assistance for a resident who required total assistance from two staff members for bed mobility. This deficiency resulted in the resident falling from the bed and sustaining a fracture to the left knee joint. The resident, who was quadriplegic and had multiple contractures, was being assisted by a CNA who attempted to change the resident's bed sheets and incontinence pad without the help of a second staff member, despite the care plan indicating the need for two-person assistance. The resident's care plan, which was current and had been revised multiple times, clearly stated that the resident required the assistance of two staff members for bed mobility due to her quadriplegia and contractures. However, the CNA proceeded to provide care alone, which led to the resident rolling off the bed and sustaining injuries. The resident had previously informed the CNA of the need for a second staff member, but the CNA assured her that he could manage alone. During the incident, the resident's leg went over the side of the bed, causing her to fall. Interviews with staff and the resident confirmed that the facility staff were aware of the requirement for two-person assistance, yet documentation showed that the resident was often recorded as needing only one-person assistance for bed mobility. This inconsistency in documentation and practice contributed to the incident. The resident's medical history, including quadriplegia, contractures, and other conditions, made her particularly vulnerable to falls, emphasizing the importance of adhering to the care plan requirements.
Resident's Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a deficiency in accommodating the needs and preferences of the resident. During a random observation, a resident was seen in a high-backed wheelchair facing the television without the call light within reach. The resident confirmed during an interview that the call light was not accessible, and he had been waiting for over an hour for assistance to be placed in bed. Later, the resident was observed lying in bed with the call light placed on his roommate's nightstand, again out of reach. The resident was unsure of the call light's location. The resident's clinical record indicated diagnoses of flaccid hemiplegia affecting the left side, vascular dementia, and other conditions requiring substantial assistance for daily activities. A care plan noted the resident's risk for falls and specified that the call light should be within reach. An LPN confirmed the call light was not within reach and suggested it was misplaced during a bedsheet change. The facility's policy mandates that call lights be accessible to residents, which was not adhered to in this instance.
Failure to Repair Damaged Wall in Resident's Room
Penalty
Summary
The facility failed to maintain a homelike environment for a resident by not repairing a damaged wall in the resident's room. The resident, who has multiple sclerosis, atherosclerosis, peripheral vascular disease, and major depressive disorder, was cognitively intact and required minimal assistance with daily activities. During an observation, a blue glove was found stuffed into a hole in the wall near the heating/cooling unit, which the resident reported was done by an x-ray technician to block cold air. The resident had requested repairs multiple times but could not recall specific dates. The administrator was unaware of the issue as no work orders had been submitted, and the facility did not use blue gloves, suggesting the glove was not from the facility. Interviews with the administrator and maintenance director revealed that the heating/cooling unit had been replaced, but no records or work orders documented this replacement. The maintenance director confirmed the unit was replaced before a deep clean of the room, but the hole was not addressed. Despite the administrator's claims of maintaining the facility in good condition, a hole was also noted in the Director of Nursing's office. The corporate nurse mentioned that the facility had a guardian angel program and regular nurse visits, implying someone should have noticed the hole. However, the facility lacked a policy for the maintenance or upkeep of physical property or resident rooms.
Failure to Provide Daily Grooming Assistance
Penalty
Summary
The facility failed to provide daily grooming assistance for a resident, identified as Resident 112, who was observed multiple times over several days without being shaved. Observations on different days showed that the resident participated in activities and meals without having been shaved, despite having facial hair growth noticeable enough to be described as the thickness of two quarters stacked. The resident's clinical record indicated severe cognitive impairment and a need for supervision or assistance with personal hygiene, yet there were no documented refusals or behaviors that would explain the lack of grooming. Interviews with Certified Nursing Assistants (CNAs) revealed inconsistencies in the shaving routine, with some indicating that shaving was done only on shower days, while others suggested it was done more frequently if needed. The Director of Nursing (DON) acknowledged that staff should attempt to shave male residents daily but could not find documentation of any refusals or behaviors from Resident 112 regarding ADL care. The facility's policy on personal hygiene, which was last revised in 2021, stated that personal hygiene, including shaving, should be performed twice daily, yet this was not adhered to in the case of Resident 112.
Failure to Provide Timely Dental Care for Resident
Penalty
Summary
The facility failed to arrange timely dental appointments for a resident who lost their lower denture, resulting in a prolonged period without the necessary dental appliance. Resident B, who was admitted in February 2023 with a full set of dentures, lost the lower plate within three months. Despite an initial appointment with Company A, the replacement denture was delayed and never arrived. The family eventually canceled the insurance with Company A and obtained a new lower denture from Company C within three weeks. However, the lower plate went missing again in December 2023, and by December 2024, the resident still did not have a replacement. The resident's clinical record indicated a history of dementia and severe cognitive impairment, but lacked documentation regarding the use of dentures. Despite a dental note from May 2023 suggesting the need for adhesive for a proper fit, the facility did not ensure the resident received a replacement lower denture. Interviews with staff revealed a lack of awareness and documentation regarding the resident's dental needs, and the Social Services Director admitted to not knowing how long the resident had been without the lower denture. The facility's policy required referrals for dental services within three days for lost or damaged dentures, but this was not adhered to in Resident B's case. The Administrator expressed reluctance to replace the denture due to the resident's refusal to wear it, but there was no documentation to support this claim. The facility's failure to address the resident's dental needs in a timely manner and lack of proper documentation contributed to the deficiency.
Inadequate COVID-19 Isolation Precautions
Penalty
Summary
The facility failed to ensure proper infection prevention and control strategies for transmission-based precautions for two residents in COVID-19 isolation. For Resident 35, multiple observations revealed the absence of a sign on the door indicating required precautions and a lack of face shields in the over-the-door organizer. RN 12 entered the resident's room wearing a gown, gloves, and an N95 mask but did not use a face shield, mistakenly believing that regular glasses sufficed. Interviews with staff confirmed the requirement for a face shield in addition to glasses unless goggles were used. The Infection Preventionist Nurse also confirmed that a sign indicating precautions should be present on the door. For Resident 67, CNA 15 incorrectly placed an N95 mask over a surgical mask before entering the resident's room, despite a sign indicating the need for contact and droplet isolation. LPN 3 informed CNA 15 of the error, but the CNA prioritized timely meal delivery over proper mask application. The Infection Preventionist Nurse confirmed that the N95 mask should not be worn over a surgical mask. Both residents had physician's orders for strict single isolation due to positive COVID-19 tests, and the facility's policy required adherence to standard precautions, including the use of a NIOSH-approved respirator, gown, gloves, and eye protection.
Failure to Monitor and Document Urinary Catheter Outputs
Penalty
Summary
The facility failed to ensure urinary catheter outputs were monitored and documented for three residents, resulting in one resident being transferred to the hospital with a large amount of urine retained from a blocked urinary catheter. Resident D, who had a history of neuromuscular dysfunction of the bladder and traumatic brain injury, was found to have inconsistent and missing documentation of urinary output. On multiple occasions, there was no recorded urine output, and Resident D was eventually transferred to the hospital with respiratory failure and a clogged catheter, leading to a urinary tract infection and significant discomfort upon catheter change. Resident H, diagnosed with quadriplegia and urinary retention, also had inconsistent documentation of urinary output. There were several days where no urine output was recorded, despite physician orders requiring documentation every shift. The lack of consistent monitoring and documentation raised concerns about the adequacy of care provided to Resident H. Resident J, with a suprapubic catheter and multiple urinary tract-related diagnoses, similarly had gaps in urinary output documentation. There were several days with no recorded urine output, despite physician orders for regular monitoring. Interviews with staff revealed that while CNAs were responsible for documenting outputs, there were lapses in ensuring this documentation was completed, and the nurses and unit manager did not consistently verify the documentation. The facility's policy on catheter care was not adhered to, leading to these deficiencies.
Failure to Administer Insulin as Ordered and Scheduled
Penalty
Summary
The facility failed to administer insulin as ordered and scheduled for two residents, Resident B and Resident C. Resident B's clinical record showed that insulin glargine, which was supposed to be administered at 8:00 p.m., was given late on multiple occasions, including at 11:44 p.m., 1:41 a.m., and 11:37 p.m. Additionally, insulin aspart was also administered late at 10:33 p.m. instead of the scheduled 5:30 p.m. Resident B had diagnoses of type 2 diabetes mellitus without complications and with diabetic neuropathy. Resident C's clinical record indicated similar issues, with insulin glargine scheduled for 8:00 p.m. being administered late at times such as 2:29 a.m., 11:20 p.m., 1:08 a.m., and 4:01 a.m. Resident C had diagnoses of type 2 diabetes mellitus with unspecified diabetic retinopathy, diabetic polyneuropathy, and hyperglycemia. During an interview, the Director of Nursing (DON) indicated that the residents were given insulin on time, but the nurses failed to document the administration correctly. The facility's policy on the timely administration of insulin mandates that insulin be administered according to physician's orders and documented accurately. The failure to adhere to this policy resulted in the cited deficiencies. This citation relates to Complaint IN00432015.
Failure to Supervise Resident During Nebulizer Treatment
Penalty
Summary
The facility failed to ensure a resident received supervision per physician order and facility policy during the administration of a nebulized medication. During a random observation, Resident G was found lying in bed with a nebulizer mask on her face and the nebulizer machine in operation, but no nurse was present in the room or hallway. Nurse Manager 9 later entered the room, turned off the nebulizer machine, and placed the nebulizer mask on top of the machine. Resident G's clinical record indicated that the nebulizer treatments were to be administered by a clinician, and the facility policy required observation of the resident during the procedure for any change in condition. Interviews with Nurse Manager 9 and LPN 13 confirmed that Resident G should have been supervised during the nebulizer treatment. LPN 13 admitted that she was supposed to supervise Resident G but was attending to another resident who needed help with his shoes. The facility's policy on Nebulizer Therapy, provided by the Director of Nursing, also indicated the necessity of observing the resident during the procedure. Resident G had multiple diagnoses, including morbid obesity with alveolar hypoventilation, obstructive sleep apnea, acute respiratory failure with hypoxia, and chronic obstructive pulmonary disease with acute exacerbation, which necessitated close supervision during nebulizer treatments.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Marion
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Colonial Oaks Health Care Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Aperion Care Marion Llc | 1.4 mi | ★★★★★ | 13 | 0 |
| Miller's Merry Manor | 2.8 mi | ★★★★★ | 2 | 0 |
| Twin City Health Care | 4.1 mi | ★★★★★ | 2 | 0 |
| University Nursing Center | 10.1 mi | ★★★★★ | 18 | 1 |
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