Health inspection·May 24, 2024

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure medically needed social services were provided for one resident (Resident #4) out of three residents reviewed. The resident was charged $100.00 for someone to accompany him each time he went out to an appointment. There were 117 residents residing in the facility at the time of the survey. Residents Affected - Few The findings included: Review of the facility's Transportation to an Appointment Policy and Procedure (no written date); Policy Statement-Our facility will assist residents in arranging transportation to/from appointments when necessary; Policy Interpretation and Implementation-1) Should it become necessary to transport a resident to an appointment, when necessary, outside the facility, the Social Service Designee or Charge Nurse shall notify the resident's representative and inform them of the appointment; 2) The resident's representative will be responsible for transporting the resident to his or her appointment; 3) Should it become necessary for the facility to provide transportation, the Social Service Designee will be responsible for arranging the transportation; 4) A member of the Nursing Staff or Social Services will accompany the resident to the appointment center when the resident's family is not available and 6) The use of volunteers to transport residents to appointments must be approved by the Director of Nursing. Review of t Resident #4 's Demographic Face Sheet documented the resident was admitted on [DATE] with a diagnosis that included but not limited to encounter for surgical aftercare following surgery on the digestive system, dysphagia, atherosclerotic heart disease, diabetes mellitus, chronic kidney disease, peripheral vascular disease, parkinsonism, depression and shortness of breath. The resident was discharged to home on 3/18/2024. Review of the Minimum Data Set (MDS) Quarterly Assessment for Resident #4 dated 3/05/2024 documented the resident had a Brief Interview of Mental Status (BIMS) Summary Score of 09 out of 15 indicating mild cognitive impairment, wore eyeglasses, required substantial/maximal to dependence assistance for ADLs (Activities of Daily Living) and had no impairment on both upper and lower extremities. Telephone interview on 5/22/2024 at 4:05 PM with the Complainant and the resident's daughter. She revealed that when her father had an appointment with the doctor, the facility required her to pay $100.00 for transportation and to have someone with him when he goes to the doctor. She stated, I communicated with a [ staff member] concerning the money for transportation. The facility would only accept $100.00 in cash. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 105498 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Susanna Wesley Health Center 5300 W 16th Avenue Hialeah, FL 33012 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)