A list of the most recent deficiencies for Wesley Homes 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-08 | 2023-09-19 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2023-08-08 | 2023-09-19 | 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 | 2023-08-08 | 2023-09-19 | 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 | 2023-08-08 | 2023-09-19 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-08 | 2023-09-19 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-08-08 | 2023-09-19 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-08-08 | 2023-09-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-08 | 2023-09-19 | 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 | 2023-08-08 | 2023-09-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-08 | 2023-09-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-08 | 2023-09-19 | 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 | 2023-08-08 | 2023-09-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-08 | 2023-09-19 | 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 | 2023-08-08 | 2023-09-19 | 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 | 2023-08-08 | 2023-09-19 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-08-08 | 2023-09-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-08 | 2023-09-19 | 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 | 2023-08-08 | 2023-09-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-08 | 2023-09-19 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-08-08 | 2023-09-19 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-08-08 | 2023-09-19 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-08-02 | 2023-08-25 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-08-02 | 2023-08-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-02 | 2023-08-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-02 | 2023-08-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-08-02 | 2023-08-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-02 | 2023-08-25 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-08-02 | 2023-08-25 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-08-02 | 2023-08-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-21 | 2023-04-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-21 | 2023-04-18 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2022-05-19 | 2022-06-20 | 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 | 2022-05-19 | 2022-06-20 | 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 | 2022-05-19 | 2022-06-20 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-05-19 | 2022-06-20 | 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 | 2022-05-19 | 2022-06-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-19 | 2022-06-20 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-05-19 | 2022-06-20 | 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 | 2022-05-19 | 2022-06-20 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-05-19 | 2022-06-20 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-05-19 | 2022-06-20 | 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 | 2022-05-19 | 2022-06-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-19 | 2022-06-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-05-19 | 2022-06-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-19 | 2022-06-20 | Y |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2022-05-17 | 2022-06-16 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-05-17 | 2022-06-16 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-05-17 | 2022-06-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-05 | 2022-06-06 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-04-26 | 2022-05-20 | Y |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-05-17 | 2022-05-17 | 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 | 2021-11-16 | 2021-12-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-16 | 2021-12-10 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-06-14 | 2019-08-13 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-06-14 | 2019-08-13 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-06-14 | 2019-08-13 | 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 | 2019-06-14 | 2019-08-13 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-06-14 | 2019-08-13 | N |
| Respond appropriately to all alleged violations. | Health | 2019-06-14 | 2019-08-13 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-06-14 | 2019-08-13 | 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 | 2019-06-14 | 2019-08-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-06-14 | 2019-08-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-14 | 2019-08-13 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-06-14 | 2019-08-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-06-14 | 2019-08-13 | N |
| Provide activities to meet all resident's needs. | Health | 2019-06-14 | 2019-08-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-06-14 | 2019-08-13 | N |
| Provide appropriate foot care. | Health | 2019-06-14 | 2019-08-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-14 | 2019-08-13 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-06-14 | 2019-08-13 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-06-14 | 2019-08-13 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-06-14 | 2019-08-13 | 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 | 2019-06-14 | 2019-08-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-14 | 2019-08-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-06-14 | 2019-08-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-14 | 2019-08-13 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-06-14 | 2019-08-13 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-06-14 | 2019-08-13 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-06-11 | 2019-06-19 | N |
