Deficiency Records for Wesley Enhanced Living at Stapeley
Updated as of November 01, 2020
This is not the most recent data for Wesley Enhanced Living at Stapeley. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-10-30 | 2019-12-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-30 | 2019-12-10 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-10-28 | 2019-12-06 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-10-28 | 2019-12-06 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-10-28 | 2019-12-06 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-10-28 | 2019-12-06 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-10-28 | 2019-12-06 | N |
| Establish methods for sharing information. | Fire Safety | 2019-10-28 | 2019-12-06 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-10-28 | 2019-12-06 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-10-28 | 2019-12-06 | N |
| Have protected exits that allow the resident to escape the building. | Fire Safety | 2019-10-28 | 2019-12-06 | 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 | 2019-10-28 | 2019-12-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-28 | 2019-12-06 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-10-28 | 2019-12-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-28 | 2019-12-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-10-28 | 2019-12-06 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-10-28 | 2019-12-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-28 | 2019-12-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-10-28 | 2019-12-06 | N |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2019-10-30 | 2019-11-30 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2019-10-30 | 2019-11-30 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-10-30 | 2019-11-30 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-10-30 | 2019-11-30 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-10-30 | 2019-11-30 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-10-30 | 2019-11-30 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-10-30 | 2019-11-30 | N |
| Respond appropriately to all alleged violations. | Health | 2019-10-30 | 2019-11-30 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-10-30 | 2019-11-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-30 | 2019-11-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-30 | 2019-11-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-30 | 2019-11-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-10-30 | 2019-11-30 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-10-30 | 2019-11-30 | 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 | 2019-10-30 | 2019-11-30 | 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 | 2019-10-30 | 2019-11-30 | 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 | 2019-10-30 | 2019-11-30 | N |
| Provide or obtain dental services for each resident. | Health | 2019-10-30 | 2019-11-30 | N |
| Dispose of garbage and refuse properly. | Health | 2019-10-30 | 2019-11-30 | N |
| 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 | 2019-10-30 | 2019-11-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-30 | 2019-11-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-12 | 2019-10-19 | Y |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-11-26 | 2019-02-14 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-11-26 | 2019-02-14 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-11-26 | 2019-02-14 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-11-26 | 2019-02-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-11-26 | 2019-02-14 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-11-26 | 2019-02-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-11-27 | 2019-01-18 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2018-11-27 | 2019-01-18 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2018-11-27 | 2019-01-18 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2018-11-27 | 2019-01-18 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2018-11-27 | 2019-01-18 | N |
| 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 | 2018-11-27 | 2019-01-18 | 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 | 2018-11-27 | 2019-01-18 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-11-27 | 2019-01-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-11-27 | 2019-01-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-11-27 | 2019-01-18 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2018-11-27 | 2019-01-18 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2018-11-27 | 2019-01-18 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-11-27 | 2019-01-18 | N |
| Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. | Health | 2018-11-27 | 2019-01-18 | N |
| Have protected exits that allow the resident to escape the building. | Fire Safety | 2018-11-26 | 2019-01-15 | 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 | 2018-11-26 | 2019-01-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-26 | 2019-01-15 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2018-11-26 | 2019-01-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-08-16 | 2018-09-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2018-05-17 | 2018-07-16 | Y |
| Meet other general requirements. | Fire Safety | 2017-10-30 | 2017-12-15 | N |
| Use approved construction type or materials. | Fire Safety | 2017-10-30 | 2017-12-15 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2017-10-30 | 2017-12-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-10-30 | 2017-12-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-10-30 | 2017-12-15 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-10-19 | 2017-11-22 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-10-19 | 2017-11-22 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-10-19 | 2017-11-22 | N |
