Deficiency Records for Wesley Woods Health and Rehabilitation
Updated as of April 01, 2024
A list of the most recent deficiencies for Wesley Woods Health and Rehabilitation. 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? |
|---|---|---|---|---|
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-22 | 2024-02-06 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-26 | 2023-06-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-09 | 2023-06-09 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-05-19 | 2023-05-20 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2023-04-25 | 2023-05-19 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-04-25 | 2023-05-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-25 | 2023-05-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-04-25 | 2023-05-04 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2023-04-25 | 2023-05-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-04-25 | 2023-04-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-25 | 2023-04-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-25 | 2023-04-26 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-06 | 2022-12-27 | Y |
| Keep all essential equipment working safely. | Health | 2022-06-23 | 2022-07-08 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-06-23 | 2022-06-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-23 | 2022-06-24 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2021-10-21 | 2021-11-05 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-09-23 | 2021-10-25 | 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 | 2021-09-23 | 2021-10-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-23 | 2021-10-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-23 | 2021-10-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-19 | 2021-09-01 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-30 | 2019-06-19 | 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 | 2019-05-30 | 2019-06-19 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-05-30 | 2019-06-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-05-30 | 2019-06-19 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-05-29 | 2019-06-19 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-05-29 | 2019-06-19 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-05-29 | 2019-06-19 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-05-29 | 2019-06-19 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-05-29 | 2019-06-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-05-29 | 2019-06-19 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2019-05-29 | 2019-06-19 | N |
