Wesley Glen, the Health Center

Based on observation, staff interview and review of facility policy, the facility failed to store food to protect them from contamination and spoilage. This had the potential to affect all 87 residents receiving food from the kitchen. The facility census was 87. Findings include: Observation of the satellite kitchen storage shelf on 04/16/26 at 9:00 A.M., revealed three bags of opened cereal. These three food items were unlabeled and undated. Interview on 04/16/26 at 9:01 A.M., with Dietary Manager #105 confirmed the items on the storage shelf were unlabeled and undated. Dietary Manager #105 observed informing kitchen staff they must label and date food items before placing them on shelf. Observation of a satellite kitchen refrigerator on 04/16/26 at 9:40 A.M., revealed one unlabeled, undated and unwrapped and exposed stick of butter. Further observation revealed previously opened, unlabeled and undated squares of cheese. Interview on 04/16/26 at 9:41 A.M., with Dining Server #162 confirmed the food items in the refrigerator were opened, unlabeled and undated. Review of the undated policy titled, Food Storage - Dry StorageBased on observation, staff interview and review of facility policy, the facility failed to store food to protect them from contamination and spoilage. This had the potential to affect all 87 residents receiving food from the kitchen. The facility census was 87.

Findings include:

Observation of the satellite kitchen storage shelf on 04/16/26 at 9:00 A.M., revealed three bags of opened cereal. These three food items were unlabeled and undated.

Interview on 04/16/26 at 9:01 A.M., with Dietary Manager #105 confirmed the items on the storage shelf were unlabeled and undated. Dietary Manager #105 observed informing kitchen staff they must label and date food items before placing them on shelf.

Observation of a satellite kitchen refrigerator on 04/16/26 at 9:40 A.M., revealed one unlabeled, undated and unwrapped and exposed stick of butter. Further observation revealed previously opened, unlabeled and undated squares of cheese.

Interview on 04/16/26 at 9:41 A.M., with Dining Server #162 confirmed the food items in the refrigerator were opened, unlabeled and undated.

Review of the undated policy titled, Food Storage - Dry Storage

Based on review of the facility fire drill reports and staff interview, the facility failed to evacuate residents in at least two fire drills per year on each shift. This had the potential to affect all 87 residents residing at the facility.

Findings include:

Review of facility fire drills completed since the last annual survey on 07/10/25 revealed fire drills were completed on 07/24/25, 08/23/25, 09/25/25, 10/22/25, 11/28/25, 12/18/25, 01/29/26, 02/28/26 and 03/30/26 with no evidence of resident evacuations being completed.

Interview on 04/16/26 at 1:15 P.M. with Life Safety Manager #159 confirmed the facility had not performed any resident evacuations for fire drills during from 07/10/25 through 04/16/26. Life Safety Manager #159 stated it was his understanding that they only had to complete one evacuation per year.

Based on observation, record review, and staff interview, the facility failed to ensure medications were properly stored. This affected one (#62) of three residents observed for medication administration. The facility census was 84.

Findings include:

Review of the medical record for Resident #62 revealed an admission date 06/01/23, with diagnoses of hypertension, hyperlipidemia, mood disorder and atherosclerotic heart disease.

Review of self administration of medications dated 09/09/25 revealed capability of unable to do for tasks related to medication administration.

Review of Brief Interview of Mental Status (BIMS) dated 09/09/25 revealed Resident #62 is Moderately cognitively impaired.

Review of physician orders dated 09/21/23 revealed Plavix oral tablet 75 milligrams (mg) one tablet by mouth in the afternoon for blood thinner.

Review of medication administration record for 07/10/25 revealed plavix oral tablet 75 mg was administered.

Observation on 07/10/25 at 11:49 A.M., revealed Resident #62 was observed with a medication cup containing one small red tablet placed in front of him. No nursing staff were found nearby, licensed nursing staff were found across the dining room attending to other staff.

Interview on 07/10/25 at 11:52 A.M., with Licensed Nurse #301 confirmed Resident #62 was left alone with his medications, she confirmed the resident does not self administer his medications.

Based on observation, staff interview, and policy review, the facility failed to store foods to protect from contamination and spoilage. This had the potential to affect all 84 residents residing in the facility.

Findings include:

Observation on 07/10/25 at 9:08 A.M., revealed the deep freezer contained opened items of garlic bread, bread sticks, pie crusts, pastry shells, and an unknown food item. These items were not labeled with open dates or use by dates. Further observation revealed chips in the dry storage with an open date of 06/21/25 and use by date of 06/28/25.

Interview on 07/10/25 at 9:10 A.M., with Dietary Manager (DM) #309 confirmed the items in the deep freezer were not labeled with open dates nor used by dates. DM #309 was unable to provide the date the items were open and what day they should be used by or discarded by.

Review of the undated policy titled, Food Storage revealed foods should be stored in a manner to prevent contamination, additionally foods should be labeled, covered, and dated when stored.

Based on observation, menu spread sheet review and staff interview, the facility failed to ensure specialty texture diets were prepared according to recipes to preserve nutrition and flavor . This had the potential to affect one (#61) of one residents who receives a pureed diet in the facility. The facility census was 84.

Findings Include:

Observation on 07/10/25 at 11:20 A.M., revealed Dietary Cook (DC) #308 revealed the preparation of pureed diet meal, which included the preparation of pureed carrots and pureed pork. This meal was also prepared using thickener. DC #308 was observed transferring shredded pork from a steam table pan into the food processor, then running the food processor for about 30 seconds. DC #308 then filled the same steam table pan with tap water and added it the food processor along with unmeasured amounts of thickener powder, then running the food processor for another 30 seconds. DC #308 was observed stopping the processor, observing the texture, then adding more tap water and more thickening powder. Once at the desired texture DC #308 put the pureed pork into smaller steam table pan.

Observations at 11:26 A.M., DC #308 was observed to begin the preparing of pureed steamed carrots which would also be prepared with thickening powder. DC #308 was observed to put the steamed carrots into the food processor from a steam table pan and running the processor for about 30 seconds. DC #308 stopped the processor, added tap water using the same steam table pan, and then added an unmeasured amount of thickening powder, then ran the food processor for another 25 seconds. DC #308 stopped the processor and again added tap water to the carrots along with more thickening powder; a new container of thickening powder was opened during the preparation of the carrots due the container previously being used for both the pork and carrots becoming empty. Once prepared to the desired texture, when placed upon a plastic utensil, upon tasting the carrots were noted to have very little to no flavor.

Review of the menu spread sheet revealed the resident pureed should received 3 ounces of pureed pork and 4 ounce of purred steamed carrots. There were no recipe provided on how the pureed diet should be pureed, including liquid to use and amounts of thicken agent to use.

Interview on 07/10/25 at 11:23 A.M., with DC #308 confirmed the use of water instead of broth being used for pureeing the pork was confirmed. DC #308 stated sometimes they will use broth instead of water but the pork was prepared with water due to not having pork broth. DC #308 confirmed the use of water instead of another flavor alternative, like vegetable broth, being used. DC #308 verfiied no recipes were being utilized for making pureed foods.

Based on observation, record review and staff interview, the facility failed to ensure no smoking signage was posted outside of resident rooms where oxygen is in use. This affected one (#40) of seven resident receiving oxygen administration. The facility census was 84.

Findings include:

Review of the medical record for Resident #40 revealed an admission date of 05/09/25, with diagnoses of chronic obstructive pulmonary disease, emphysema and dementia.

Review of physician order dated 05/09/25 revealed continuous oxygen administration at 2.5 liters (L) via nasal cannula (NC).

Review of treatment administration record dated 07/10/25 revealed oxygen 2.5 L via NC was administered for shortness of breath and oxygen administration percentage below 90 percent.

Observation on 07/10/25 at 10:13 A.M. and 11:53 A.M., of Resident #40's was utilizing oxygen. There was no signage posted at the door for no smoking.

Interview on 07/10/25 at 2:47 P.M., with Director of Assisted Living #308 confirmed Resident #40 did not have signage present on the door to indicate no smoking, and it should be posted.