A list of the most recent deficiencies for Wesley Enhanced Living at Stapeley. 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 generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-03 | 2023-11-16 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-10-03 | 2023-11-10 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-10-03 | 2023-11-10 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-10-03 | 2023-11-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-03 | 2023-11-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-10-03 | 2023-11-10 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-10-03 | 2023-11-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-10-03 | 2023-11-10 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-10-03 | 2023-11-10 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-10-03 | 2023-11-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-03 | 2023-11-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-09-28 | 2023-11-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-28 | 2023-11-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-28 | 2023-11-01 | N |
| Post nurse staffing information every day. | Health | 2023-09-28 | 2023-11-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-28 | 2023-11-01 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2023-09-28 | 2023-11-01 | N |
| Keep all essential equipment working safely. | Health | 2023-09-28 | 2023-11-01 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-09-28 | 2023-11-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-11-21 | 2022-12-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-21 | 2022-12-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-21 | 2022-12-25 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-11-15 | 2022-12-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-15 | 2022-12-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-15 | 2022-12-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-15 | 2022-12-22 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-11-15 | 2022-12-22 | 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 | 2022-11-15 | 2022-12-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-11-15 | 2022-12-22 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-02-04 | 2022-03-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-04 | 2022-03-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-04 | 2022-03-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-02-04 | 2022-03-21 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2022-02-04 | 2022-03-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-04 | 2022-03-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-02-04 | 2022-03-21 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-01-13 | 2022-03-01 | Y |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-01-13 | 2022-03-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-06-07 | Not Fixed | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-07 | Not Fixed | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-06-07 | Not Fixed | Y |
