A list of the most recent deficiencies for Wesley Glen Health Services Corp. 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 | 2023-06-06 | 2023-07-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-06 | 2023-07-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-06-06 | 2023-07-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-06 | 2023-07-05 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-03-30 | 2023-05-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-16 | 2022-10-26 | N |
| Respond appropriately to all alleged violations. | Health | 2022-09-16 | 2022-10-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-16 | 2022-10-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-16 | 2022-10-26 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-09-16 | 2022-10-26 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-09-06 | 2022-10-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-09-06 | 2022-10-26 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-09-06 | 2022-10-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-09-06 | 2022-10-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-01 | 2021-07-12 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-04-29 | 2021-07-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-29 | 2021-07-12 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2020-02-20 | 2020-04-05 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2020-02-20 | 2020-04-05 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-02-20 | 2020-04-05 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2020-02-20 | 2020-04-05 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-02-20 | 2020-04-05 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-02-20 | 2020-04-05 | N |
| Respond appropriately to all alleged violations. | Health | 2020-02-20 | 2020-04-05 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2020-02-20 | 2020-04-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-20 | 2020-04-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-02-20 | 2020-04-05 | 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 | 2020-02-20 | 2020-04-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-20 | 2020-04-05 | 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 | 2020-02-20 | 2020-04-05 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2020-02-19 | 2020-04-05 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-02-19 | 2020-04-05 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2020-02-19 | 2020-04-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-19 | 2020-04-05 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-02-19 | 2020-04-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-01-04 | 2019-02-15 | 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 | 2019-01-04 | 2019-02-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-01-04 | 2019-02-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-01-04 | 2019-02-15 | 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 | 2019-01-04 | 2019-02-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-01-04 | 2019-02-15 | 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 | 2019-01-04 | 2019-02-15 | 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 | 2019-01-04 | 2019-02-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-04 | 2019-02-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-01-03 | 2019-02-15 | N |
