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Deficiency Records for Wexford Healthcare Center
A list of the most recent deficiencies for Wexford Healthcare Center. 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 Wexford Healthcare 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-08-21 | 2024-09-16 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-08-21 | 2024-09-16 | Y |
| 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 | 2024-07-24 | 2024-08-08 | Y |
| Keep all essential equipment working safely. | Health | 2024-06-26 | 2024-07-22 | Y |
| 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 | 2024-06-06 | 2024-07-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-06-06 | 2024-07-08 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-06-06 | 2024-07-08 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-06-06 | 2024-07-08 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-06-06 | 2024-07-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-05-22 | 2024-06-25 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-05-22 | 2024-06-25 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-05-22 | 2024-06-25 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-05-22 | 2024-06-25 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-03-28 | 2024-04-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-28 | 2024-04-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-16 | 2024-03-29 | Y |
| 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 | 2024-02-16 | 2024-03-29 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-27 | 2023-12-08 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-27 | 2023-12-08 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-10-27 | 2023-12-08 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2023-10-27 | 2023-12-08 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-10-27 | 2023-12-08 | 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 | 2023-10-27 | 2023-12-08 | 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 | 2023-10-27 | 2023-12-08 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-27 | 2023-12-08 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-10-27 | 2023-12-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-27 | 2023-12-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-27 | 2023-12-08 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-10-27 | 2023-12-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-27 | 2023-12-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-27 | 2023-12-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-27 | 2023-12-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-10-27 | 2023-12-08 | 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 | 2023-10-27 | 2023-12-08 | 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 | 2023-10-27 | 2023-12-08 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-10-27 | 2023-12-08 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-10-27 | 2023-12-08 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-10-27 | 2023-12-08 | 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 | 2023-10-27 | 2023-12-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-27 | 2023-12-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-27 | 2023-12-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-27 | 2023-12-08 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-10-27 | 2023-12-08 | Y |
| 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 | 2023-10-27 | 2023-12-08 | Y |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-10-25 | 2023-12-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-25 | 2023-12-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-25 | 2023-12-08 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-10-25 | 2023-12-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-25 | 2023-12-08 | 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 | 2023-09-05 | 2023-10-05 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-09-05 | 2023-10-05 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2023-09-05 | 2023-10-05 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-16 | 2023-04-12 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-03-16 | 2023-04-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-21 | 2023-03-07 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-02-21 | 2023-03-07 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-21 | 2023-03-07 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-01-26 | 2023-03-01 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-01-26 | 2023-03-01 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-03 | 2022-12-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-03 | 2022-12-23 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-11-03 | 2022-12-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-03 | 2022-12-23 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-11-08 | 2022-12-13 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-11-08 | 2022-12-13 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-11-08 | 2022-12-13 | N |
| Respond appropriately to all alleged violations. | Health | 2022-11-08 | 2022-12-13 | 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 | 2022-11-08 | 2022-12-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-08 | 2022-12-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-08 | 2022-12-13 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-11-08 | 2022-12-13 | 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 | 2022-11-08 | 2022-12-13 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-11-08 | 2022-12-13 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-11-08 | 2022-12-13 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-11-08 | 2022-12-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-08 | 2022-12-13 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2022-11-08 | 2022-12-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-08 | 2022-12-13 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-11-08 | 2022-12-13 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-11-08 | 2022-12-13 | 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 | 2022-11-08 | 2022-12-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-08 | 2022-12-13 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-11-08 | 2022-12-13 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-08 | 2022-12-13 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-11-08 | 2022-12-13 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-09-15 | 2022-10-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-15 | 2022-09-15 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-08-31 | 2022-09-13 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2022-08-31 | 2022-09-13 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-04-06 | 2022-05-10 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-04-06 | 2022-05-10 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-06 | 2022-05-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-06 | 2022-05-10 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-06 | 2022-05-10 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-04-06 | 2022-05-10 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-04-06 | 2022-05-10 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-04-06 | 2022-05-10 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-27 | 2022-03-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-27 | 2022-03-01 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-11 | 2021-12-14 | 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 | 2021-11-11 | 2021-12-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-11 | 2021-12-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-11 | 2021-12-14 | 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 | 2021-11-11 | 2021-12-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-11-11 | 2021-12-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-11-11 | 2021-12-14 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-11-11 | 2021-12-14 | Y |
| Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. | Health | 2021-11-11 | 2021-12-14 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-11-23 | 2021-12-10 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-11-11 | 2021-11-11 | N |
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