Deficiency Records for Wesley Homes Health Center
Updated as of April 01, 2020
This is not the most recent data for Wesley Homes Health Center. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-29 | 2019-11-08 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2019-09-30 | 2019-11-08 | 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 ne | 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 |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-22 | 2019-04-12 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-11-09 | 2018-12-21 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-03-26 | 2018-05-10 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-03-26 | 2018-05-10 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2018-03-26 | 2018-05-10 | 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 | 2018-03-26 | 2018-05-10 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-03-26 | 2018-05-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-03-26 | 2018-05-10 | 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 | 2018-03-26 | 2018-05-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-03-26 | 2018-05-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-03-26 | 2018-05-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-03-26 | 2018-05-10 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2018-03-26 | 2018-05-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-03-26 | 2018-05-10 | 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 | 2018-03-26 | 2018-05-10 | 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 ne | Health | 2018-03-26 | 2018-05-10 | 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 | 2018-03-26 | 2018-05-10 | N |
| Provide or obtain dental services for each resident. | Health | 2018-03-26 | 2018-05-10 | 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 | 2018-03-26 | 2018-05-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-03-26 | 2018-05-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-03-26 | 2018-05-10 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-03-26 | 2018-05-10 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-03-15 | 2018-04-13 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2018-03-15 | 2018-04-13 | N |
| Install proper backup exit lighting. | Fire Safety | 2018-03-15 | 2018-04-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-03-15 | 2018-04-13 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-03-15 | 2018-04-13 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-03-15 | 2018-04-13 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-03-15 | 2018-04-13 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-10-02 | 2017-11-13 | Y |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-08-03 | 2017-09-15 | Y |
| Give residents a notice of rights, rules, services and charges. | Health | 2016-12-06 | 2017-01-20 | N |
| Provide residents with private access to a telephone. | Health | 2016-12-06 | 2017-01-20 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2016-12-06 | 2017-01-20 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2016-12-06 | 2017-01-20 | N |
| Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. | Health | 2016-12-06 | 2017-01-20 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2016-12-06 | 2017-01-20 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2016-12-06 | 2017-01-20 | N |
| Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients. | Health | 2016-12-06 | 2017-01-20 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-12-06 | 2017-01-20 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2016-12-06 | 2017-01-20 | N |
| Use a registered nurse at least 8 hours a day, 7 days a week. | Health | 2016-12-06 | 2017-01-20 | N |
| Post nurse staffing information/data on a daily basis. | Health | 2016-12-06 | 2017-01-20 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-12-06 | 2017-01-20 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-12-06 | 2017-01-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2016-12-01 | 2016-12-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2016-12-01 | 2016-12-02 | N |
