Lilac Manor Rehabilitation And Nursing Center

F-F760: Residents are Free of Significant Medication Errors

During an interview on 5/31/24 at 10:45 AM, the Corporate Maintenance Director stated that for maintenance it was just themself, because one of the maintenance staff was out on medical leave and the other one left about two weeks ago.

For six residents reviewed for allegations of resident abuse and injuries with unknown origin, the facility could not provide evidence that the allegations were thoroughly investigated.

During an interview on 6/3/24 at 10:05 AM, the Corporate Infection Preventionist stated it was identified in either February or March 2024 that investigations were missing, likely due to changes in facility leadership.

For three residents reviewed the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene as related to nail care, shaving, bathing, hair washing and hair trimming.

Resident #52 did not receive consistent psychiatric services, did not receive medication changes as recommended, and did not have a comprehensive care plan that included an individualized person-centered approach to address their behavioral health needs.

During an interview on 6/4/24 at 9:57 AM, the Corporate Director of Resident Services stated that there had been a discrepancy with telepsychiatry visits as the telepsychiatry providers called and cancelled due to the facility not having clinical staff to sit with the residents during their appointments and issues with the providers not being made aware of the telepsychiatry recommendations.

For four residents reviewed for medication administration, the facility did not ensure that the residents were free from significant medication errors as they related to omissions of significant medications being administered and incorrect doses of narcotic pain medication being administered.

For five of five occupied resident-use floors and one of one basement the facility did not properly maintain all essential mechanical, electrical, and resident care equipment in safe operating condition.

Specifically, laundry equipment, hot water boilers, a mechanical dish washing machine, patient care lifts, and ventilation systems were not maintained in working order.

335488

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 335488 B.

Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wesley Gardens Corporation 3 Upton Park Rochester, NY 14607