Inspection Reports for Wisteria Place Retirement Living

The complaint investigation focused on Resident #1, who experienced a significant change in condition that was not reported to the physician, and a medication error involving administration of Losartan potassium outside of prescribed blood pressure parameters. The facility was found to have failed in notifying the physician and family members appropriately, resulting in an Immediate Jeopardy status that was later removed after corrective actions.

The facility failed to notify the physician of Resident #1's change in condition involving passing large amounts of watery fluids through his ileostomy and failed to report a medication error where blood pressure medication was administered outside prescribed parameters. These failures placed residents at risk of delayed medical intervention, decline in health, serious injury, or death.

The facility was found deficient in several areas including failure to discontinue unnecessary psychotropic medications after 14 days without documented rationale, failure to develop comprehensive care plans including advance directive information for some residents, improper food handling and sanitation practices in the kitchen, and failure to employ a full-time qualified social worker despite having a capacity over 120 beds.

The facility was found deficient in developing comprehensive care plans reflecting residents' advanced directives, maintaining medication storage free of expired products, ensuring a licensed social worker was on staff as per plan of correction, and implementing effective quality assessment and assurance activities. These deficiencies posed risks of care not aligned with resident preferences, delayed wound healing, unmet psychosocial needs, and inadequate quality improvement oversight.

The facility was found deficient in developing comprehensive care plans that include residents' advanced directives, maintaining up-to-date DNR information in nurse station binders, removing expired treatment products from medication carts, and ensuring the Quality Assessment and Assurance Committee (QAPI) effectively implements corrective actions including staffing a licensed social worker.

The complaint investigation found that the facility did not send required transfer or discharge notices to the Ombudsman as required, with no 30-day discharge notices received since 3/21/2022 and no transfer/discharge reports since 6/7/2023. The social worker was unaware of the requirement to notify the Ombudsman of all transfers and discharges.

The facility failed to send a written notice of transfer or discharge and the reasons for the transfer or discharge to the Office of the State Long-Term Care Ombudsman for one resident discharged on 7/14/23. This failure could place residents at risk of being discharged without access to advocacy services and appeal processes. Interviews revealed lack of awareness about notification requirements among staff.

The complaint investigation found that Resident #1 was sent to the hospital on a Monday morning but the family was not notified until the following day, more than 24 hours later. The Infection Control RN who made the decision to send the resident to the hospital failed to notify the family immediately due to distractions and oversight. The Director of Nursing confirmed the failure and took disciplinary action against the nurse. The family expressed upset over the delayed notification.

The facility failed to notify Resident #1's family or Power of Attorney within 24 hours after the resident was admitted to the hospital for serious medical complications. This failure posed a risk to all residents for not having timely family notification during significant changes in condition. Disciplinary action was taken against the responsible nurse, and staff in-service training was initiated to address the issue.

The facility was found deficient in maintaining a safe environment free of hazards, proper medication storage and supervision, adherence to menu plans, food safety and hygiene practices, hiring a qualified social worker, and implementing infection prevention and control protocols.

The facility was found to have multiple deficiencies including unsafe storage of cleaning agents, unlocked medication carts, unsecured respiratory medications, failure to follow menu plans, improper food storage and hygiene practices, unlicensed social worker employed, and lapses in infection prevention and control practices such as improper mask use and inadequate hand hygiene during sterile procedures.