A list of the most recent deficiencies for Wesley Gardens Corporation. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-02-08 | 2023-04-09 | 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 | 2023-02-08 | 2023-04-09 | N |
| Post nurse staffing information every day. | Health | 2023-02-08 | 2023-04-09 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2023-02-08 | 2023-04-09 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-02-08 | 2023-04-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-08 | 2023-04-09 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-11-22 | 2022-12-27 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-17 | 2022-04-30 | 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 | 2022-03-17 | 2022-04-30 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-09-18 | 2021-10-29 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-04-23 | 2021-06-23 | N |
| Respond appropriately to all alleged violations. | Health | 2021-04-23 | 2021-06-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-23 | 2021-06-22 | N |
| Provide activities to meet all resident's needs. | Health | 2021-04-23 | 2021-06-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-04-23 | 2021-06-22 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-04-23 | 2021-06-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-23 | 2021-06-22 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-04-23 | 2021-06-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-23 | 2021-06-22 | Y |
| Use approved construction type or materials. | Fire Safety | 2021-04-23 | 2021-06-22 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2021-04-23 | 2021-06-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-04-23 | 2021-06-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-04-23 | 2021-06-22 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-08-22 | 2019-10-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-22 | 2019-10-29 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-08-22 | 2019-10-29 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-08-22 | 2019-10-01 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-08-22 | 2019-10-01 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-08-22 | 2019-10-01 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-08-22 | 2019-10-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-08-22 | 2019-10-01 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-08-22 | 2019-10-01 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-08-22 | 2019-10-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-22 | 2019-10-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-08-22 | 2019-10-01 | N |
| Provide activities to meet all resident's needs. | Health | 2019-08-22 | 2019-10-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-08-22 | 2019-10-01 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-08-22 | 2019-10-01 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-08-22 | 2019-10-01 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2019-08-22 | 2019-10-01 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-08-22 | 2019-10-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-08-22 | 2019-10-01 | 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 | 2019-08-22 | 2019-10-01 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2019-08-22 | 2019-10-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-22 | 2019-10-01 | 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 | 2019-08-22 | 2019-10-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-22 | 2019-10-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-08-22 | 2019-10-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-08-22 | 2019-10-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-22 | 2019-10-01 | N |
| Use approved construction type or materials. | Fire Safety | 2019-08-22 | Not Fixed | N |
