A list of the most recent deficiencies for Wesley Manor Health Center. 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-28 | 2023-10-20 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-04-04 | 2023-05-17 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-04-04 | 2023-05-17 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-04-04 | 2023-05-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-04 | 2023-05-17 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-04-04 | 2023-05-17 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-04-20 | 2023-05-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-20 | 2023-05-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-20 | 2023-05-08 | 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 | 2022-04-13 | 2022-05-11 | 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 | 2022-04-13 | 2022-05-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-04-19 | 2022-05-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-19 | 2022-05-04 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2020-01-06 | 2020-02-05 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2020-01-06 | 2020-02-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-01-06 | 2020-02-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-06 | 2020-02-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-01-06 | 2020-02-05 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-11-20 | 2019-12-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-20 | 2019-12-10 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-11-20 | 2019-12-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-20 | 2019-12-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-20 | 2019-12-10 | 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 | 2019-11-20 | 2019-12-10 | 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 | 2019-11-20 | 2019-12-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-20 | 2019-12-10 | N |
