A list of the most recent deficiencies for Wealshire Ctr of Excellence. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-31 | 2023-11-09 | Y |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-10-31 | 2023-11-09 | Y |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-10-31 | 2023-11-09 | Y |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-31 | 2023-11-09 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-15 | 2023-07-05 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-05-15 | 2023-07-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-15 | 2023-06-09 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-05-15 | 2023-06-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-15 | 2023-06-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-15 | 2023-06-09 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-05-15 | 2023-06-09 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-05-15 | 2023-06-09 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-05-15 | 2023-06-09 | Y |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2023-05-15 | 2023-06-09 | Y |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-03-23 | 2023-04-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-23 | 2023-03-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-22 | 2023-03-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-03-23 | 2023-03-23 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-03-23 | 2023-03-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-19 | 2023-01-23 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-25 | 2022-09-01 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-08 | 2022-02-18 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-02-08 | 2022-02-11 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-02-08 | 2022-02-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-08 | 2022-02-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-02-08 | 2022-02-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-02-08 | 2022-02-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-26 | 2022-02-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-26 | 2022-02-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-26 | 2022-02-02 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-01-26 | 2022-02-02 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-01-26 | 2022-02-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-26 | 2022-02-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-02-18 | 2021-03-08 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-02-18 | 2021-03-05 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2021-02-18 | 2021-03-05 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2021-02-18 | 2021-03-05 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-02-18 | 2021-03-05 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-02-18 | 2021-03-05 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-02-18 | 2021-03-05 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-02-18 | 2021-03-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-02-10 | 2021-02-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-02-10 | 2021-02-11 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-02-10 | 2021-02-11 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-02-10 | 2021-02-11 | N |
