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Deficiency Records for Wedgemere Healthcare
A list of the most recent deficiencies for Wedgemere Healthcare. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Wedgemere Healthcare. 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? |
|---|---|---|---|---|
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-12-18 | 2024-01-18 | N |
| Respond appropriately to all alleged violations. | Health | 2023-12-18 | 2024-01-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-18 | 2024-01-18 | 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 | 2023-12-18 | 2024-01-18 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-12-12 | 2024-01-08 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-12-12 | 2024-01-08 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2023-12-12 | 2024-01-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-12 | 2024-01-08 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-12-12 | 2024-01-08 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-12-18 | 2024-01-05 | 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 | 2023-12-18 | 2024-01-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-12-18 | 2024-01-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-18 | 2024-01-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-12-18 | 2024-01-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-18 | 2024-01-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-18 | 2024-01-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-18 | 2024-01-05 | 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 | 2023-12-18 | 2024-01-05 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-12-18 | 2024-01-05 | 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 | 2023-12-18 | 2024-01-05 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-12-18 | 2024-01-05 | 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 | 2023-12-18 | 2024-01-05 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-12-18 | 2024-01-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-18 | 2024-01-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-18 | 2024-01-05 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-12-18 | 2024-01-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-08 | 2023-11-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-08 | 2023-11-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-10-03 | 2023-10-27 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-10-03 | 2023-10-27 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-10-13 | 2021-12-01 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-10-13 | 2021-12-01 | 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 | 2021-10-13 | 2021-12-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-10-13 | 2021-12-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-13 | 2021-12-01 | 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 | 2021-10-13 | 2021-12-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-10-13 | 2021-12-01 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-10-13 | 2021-12-01 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-10-13 | 2021-12-01 | 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 | 2021-10-13 | 2021-12-01 | 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 | 2021-10-13 | 2021-12-01 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-10-13 | 2021-12-01 | N |
| Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-10-13 | 2021-12-01 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-10-13 | 2021-12-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-13 | 2021-12-01 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-10-13 | 2021-10-29 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-10-13 | 2021-10-29 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-10-13 | 2021-10-29 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-10-13 | 2021-10-29 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-08-31 | 2020-09-10 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-08-31 | 2020-09-10 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2020-01-29 | 2020-02-21 | N |
| Dispose of garbage and refuse properly. | Health | 2020-01-29 | 2020-02-21 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-01-29 | 2020-02-21 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-01-29 | 2020-02-21 | N |
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