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Deficiency Records for Wesley Gardens Corporation
A list of the most recent deficiencies for Wesley Gardens Corporation. 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 Wesley Gardens Corporation. 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 safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-06-06 | 2024-09-04 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-06-06 | 2024-09-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-06-06 | 2024-09-04 | N |
| Post nurse staffing information every day. | Health | 2024-06-06 | 2024-09-04 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-06-06 | 2024-09-04 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-06-06 | 2024-09-04 | 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 | 2024-06-06 | 2024-09-04 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-06-06 | 2024-09-04 | N |
| Keep all essential equipment working safely. | Health | 2024-06-06 | 2024-09-04 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2024-06-06 | 2024-09-04 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-06-06 | 2024-09-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-06-06 | 2024-09-04 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-06-06 | 2024-09-04 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2024-06-06 | 2024-08-05 | 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 | 2024-06-06 | 2024-08-05 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-06-06 | 2024-08-05 | N |
| Respond appropriately to all alleged violations. | Health | 2024-06-06 | 2024-08-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-06-06 | 2024-08-05 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-06-06 | 2024-08-05 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-06-06 | 2024-08-05 | 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 | 2024-06-06 | 2024-08-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-06-06 | 2024-08-05 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-06-06 | 2024-08-05 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2024-06-06 | 2024-08-05 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-06-06 | 2024-08-05 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2024-06-06 | 2024-08-05 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2024-06-06 | 2024-08-05 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-06-06 | 2024-08-05 | N |
| Meet the requirements of an integrated health system. | Fire Safety | 2024-06-06 | 2024-08-05 | N |
| Use approved construction type or materials. | Fire Safety | 2024-06-06 | 2024-08-05 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-06-06 | 2024-08-05 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-06-06 | 2024-08-05 | 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 | 2024-06-06 | 2024-08-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-06-06 | 2024-08-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-06-06 | 2024-08-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-06-06 | 2024-08-05 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-06-06 | 2024-08-05 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2024-06-06 | 2024-08-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-06-06 | 2024-08-05 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-06-06 | 2024-08-05 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2024-06-06 | 2024-08-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-06-06 | 2024-08-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-08 | 2023-04-09 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-02-08 | 2023-04-09 | 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 | 2023-02-08 | 2023-04-09 | N |
| Post nurse staffing information every day. | Health | 2023-02-08 | 2023-04-09 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2023-02-08 | 2023-04-09 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-02-08 | 2023-04-09 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-11-22 | 2022-12-27 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-17 | 2022-04-30 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-03-17 | 2022-04-30 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-04-23 | 2021-06-23 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-04-23 | 2021-06-22 | N |
| Respond appropriately to all alleged violations. | Health | 2021-04-23 | 2021-06-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-23 | 2021-06-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-23 | 2021-06-22 | N |
| Provide activities to meet all resident's needs. | Health | 2021-04-23 | 2021-06-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-04-23 | 2021-06-22 | 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 | 2021-04-23 | 2021-06-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-23 | 2021-06-22 | N |
| Use approved construction type or materials. | Fire Safety | 2021-04-23 | 2021-06-22 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2021-04-23 | 2021-06-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-04-23 | 2021-06-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-04-23 | 2021-06-22 | N |
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