Wesley Health Care Center Inc

Inspectors wroteBased on record review and interviews during survey, the facility failed to ensure that resident records were complete and accurately documented for one (Resident #6) of nine residents reviewed for resident-identifiable information. Specifically, Resident #6 had a suprapubic catheter (a hollow flexible tube that is used to drain urine from the bladder through a cut in the abdomen), and was ordered to have urine output recorded every shift. The output was not consistently documented in March through June of 2026.

Inspectors wroteBased on observations, interviews, and record reviews conducted during survey, the facility failed to ensure residents' right to be free from abuse. Specifically, between 06/29/2025 and 06/14/2026, staff witnessed and documented Residents #1, 3, 5 and 10 verbally and/or physically abusing other residents but did not take action to prevent residents from further abuse. This resulted in actual harm (psychosocial and physical) to Resident #4 that was Immediate Jeopardy and had likelihood to place other vulnerable residents at risk for serious harm, serious injury, serious impairment, or death.

Inspectors wroteBased on record review and interviews during a survey, the facility failed to ensure alleged violations involving abuse, were reported immediately, but not later than two (2) hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to officials (including to the State Agency) for three (Residents #s 4, 5, and 10) of 10 residents reviewed for abuse. Specifically, on 07/05/2025, Resident #10 had a physical altercation with Resident #4, resulting in Resident # 4 having bruises; on 06/14/2026, Resident #5 threatened to kill other residents; and on 11/02/2025, Resident #10 was noted to taunt and threaten other residents causing distress. These incidents were not reported to the State Survey Agency.

Inspectors wroteBased on observation, record review, and interviews conducted during survey, the facility failed to ensure allegations of abuse were investigated for two (Resident #5, and 10) of two residents reviewed. Specifically, staff witnessed and documented in Progress Notes Resident #'s 5, and 10 verbally and/or physically abused other residents. There was no documented evidence of investigations of these incidents.

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections. Specifically, (a) the facility had an outbreak of COVID 19 that started 7/11/2024 and continued through the survey with 174 (6 admitted w/Covid) resident positives and 100 staff positives and positive residents located in all units throughout the facility; [...]

Inspectors wroteBased on observation and interviews during the recertification survey, the facility did not ensure that food was stored, prepared, distributed, or served in accordance with professional standards for food service safety in 8 of 8 resident unit kitchenettes. Specifically, the area of the resident kitchenettes was not clean, and open containers were not appropriately labeled when they were opened. This is evidenced by: The facility policy titled Area and Equipment Cleaning revised January 2024 documented that the kitchen staff have procedures in place for daily and weekly cleaning of all areas and equipment and documenting on the equipment cleaning log and master cleaning schedule. [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey and abbreviated survey (NY00356338), the facility did not ensure each resident was treated with respect and dignity and cared for in a manner and in an environment that promoted maintenance or enhancement of their quality of life, recognizing each resident's individuality for 2 (Resident #s 6 and 33) of 7 residents reviewed for dignity. Specifically, for (a.) Resident #6 was left to soil themselves because staff did not attend to the resident in a timely fashion, leaving the resident feeling humiliated on more than one occasion. Resident #33 was not assisted with the consumption of their observed meal in a dignified manner. This is evidenced by: [...]

Inspectors wroteBased on record review and interviews during the recertification survey, the facility did not ensure that each resident was screened for a mental disorder or intellectual disability prior to admission for 1 (Resident #243) of 35 residents reviewed. Specifically, there was no documentation that a Preadmission Screening and Resident Review (PASARR, New York State Department of Health form 695) was completed for Resident #243 by a qualified screener prior to admission to the facility. This is evidenced by: Resident #243 was admitted to the facility with diagnoses of malignant neoplasm of prostate (prostate cancer that spread to other parts of the body), secondary malignant neoplasm of bone (cancer that spread to the bone from the prostate), and difficulty walking. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during a recertification survey, the facility did not ensure Comprehensive Care Plans were reviewed after each assessment and revised based on changing goals, preferences, and needs of the resident and in response to current interventions for 1 (Resident #68) of 39 residents reviewed. Specifically, for Resident #68, the Comprehensive Care Plan for Respiratory Therapy was not reviewed and revised to include changes in the resident's respiratory status when resident was not using oxygen. This is evidenced by: A review of the facility policy titled Respiratory Therapy Program dated 4/18/2023 documented the facility was to provide respiratory therapy assessment and treatment to those residents with deficiencies or abnormalities of pulmonary function, for whom a provider's order has been written. [...]

Inspectors wroteBased on observations, record review, and interviews during a recertification survey, the facility did not ensure that it provided an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 1 (Resident # 80) of 2 residents reviewed for activities. Specifically, Resident #80 was not provided with activities that met the residents' preferences and cognitive abilities. This is evidenced by: [...]

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure that each resident received the necessary respiratory care and services that were following professional standards of practice, for 3 (Residents #'s 49, 53, and 68) of 6 residents reviewed for oxygen administration. Specifically, (a) for Residents #49, 53, and 68, their supplemental oxygen tubing was not dated and labeled to reflect when the tubing was changed; and (b) supplemental oxygen was not provided as ordered by the physician for Resident #68. This is evidenced by: A review of the facility policy titled Respiratory Therapy Program dated 4/18/2023 documented the facility was to provide respiratory therapy assessment and treatment to those residents with deficiencies or abnormalities of pulmonary function, for whom a provider's order had been written. [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey, the facility did not maintain medical records in accordance with accepted professional standards and practices that were accurately documented and completed for 1 (Resident #68) of 39 residents reviewed. Specifically, for Resident #68 staff was observing and verifying every four hours that the resident's oxygen nasal canula was in place and the resident was using the oxygen as prescribed by the physician. This is evidenced by: A review of the facility policy titled Respiratory Therapy Program dated 4/18/2023 documented the facility was to provide respiratory therapy assessment and treatment to those residents with deficiencies or abnormalities of pulmonary function, for whom a provider's order has been written. [...]

Inspectors wroteBased on record review and interview during the recertification survey, the facility did not ensure a policy was developed for the monthly medication regimen review (MRR) that included time frames for the different steps in the process when an irregularity that requires urgent action to protect the resident is identified. This is evidenced by: On 9/29/2021, the facility Administrator provided a policy titled; Medication Regimen Review, revised on 5/2019 and reviewed on 6/2021. The policy documented; If in the professional judgment of the Pharmacist, there is an irregularity that requires immediate action, the Pharmacist will report the irregularity to the Unit Charge Nurse and Attending Physician immediately. The policy did not include the steps to be taken or timeframes for the Unit Charge Nurse and Attending Physician's response to the reported irregularity requiring immediate action. [...]

Inspectors wroteBased on observation, record review, and staff interview during the recertification survey, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety. A test kit is to be provided that accurately measures the parts per million (ppm) concentration of the chemical solution used to sanitize equipment, and dishwashing machines are to be operated in accordance with the manufactures' instructions. Specifically, an accurate test kit was not provided, and the automatic dishwashing machine was not operating according to the manufacturer's instructions. This is evidenced as follows. The main kitchen was inspected on 09/29/2021 at 9:57 AM. The bottle label of chemical concentrate used to sanitize food equipment in the 3-compartment sink stated the dilution is to be between 200 ppm and 400 ppm; [...]

Inspectors wroteBased on observation, record review, and staff interview during the recertification survey, the facility did not ensure foods brought to residents is in accordance with adopted regulations. Specifically, the facility did not adhere to its established policy on food brought to residents and did not provide information for family and other visitors on safe food handling practices of food that they bring to residents. This is evidenced is as follows. The nursing unit kitchenette refrigerators were inspected for food brought in by or to residents on 09/29/2021 at 11:22 AM. On the 2 [NAME] Unit, food for Resident #220 was not dated. On the 3 [NAME] Unit, food had the name of Resident #6 and was dated; and a serving of turkey and rice was not dated and did not have a resident name. On the 4 [NAME] Unit, food for Residents #'s 50 and #156 were not dated. The facility policy Foods from Outside: [...]

Inspectors wroteBased on observation, record review, and staff interview during the recertification survey, the facility did not maintain a pest-free environment and an effective pest control program. Specifically, the facility did not maintain an adequate pest control program as evidenced by sightings of flying insects in the main kitchen. This is evidenced as follows. Observations on 09/29/2021 at 9:57 AM, revealed tiny flies surrounding the ice machine located in the main kitchen. Additionally, the drain servicing the ice machine was soiled with grime. The Dining Services Director stated in an interview on 09/29/2021 at 9:57 AM, that the flies may be coming from the floor drain by the ice machine. Record review of the pest-control service reports on 09/29/2021, revealed that fruit fly activity was noted on 08/24/2021, 09/07/2021, 09/14/2021, and 09/21/2021. [...]

Inspectors wroteBased on observation, record review, and interviews during a recertification survey, the facility did not provide the resident and their representative with a written summary of the baseline care plan for 4 (Resident #'s 42, 65, 132 and #316) of 20 residents reviewed. Specifically, for Resident #'s 42, 65, 132 and #316, the facility did not ensure written summaries of the baseline care plans were provided to the resident and the resident's representative. This is evidenced by: Resident #42: The resident was admitted on [DATE], with the diagnoses of hypertension, arthritis, dementia, and alcohol dependence. The Minimum Data Set (MDS) dated [DATE], assessed that the resident understands, was understood and had a slight cognitive impairment. [...]

Inspectors wroteBased on record review and interview during the recertification survey, the facility did not ensure a policy was developed for the monthly Medication Regimen Review (MRR) that included time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. Specifically, the facility did not ensure that time frames were established for the steps in the MRR process. This is evidenced by: The Policy for Medication Regimen Review (undated) documented: 1. Results of Pharmacy Review findings (which require Physician response) are written on Pharmacy Review Sheet. 2. Physician indicates response to Pharmacist findings then signs and dates the form. 3. [...]

Inspectors wroteBased on record review and interview during the recertification survey, the facility did not ensure it had a policy regarding use and storage of foods brought to residents by family and visitors to ensure safe and sanitary storage, handling, and consumption. Specifically, the facility did not provide information for family and visitors on safe food preparation and handling practices. This was evidenced as follows: Review of the facility's Policy on Food Brought in from the Outside on 5/15/19 documented that the facility was responsible for providing residents, family, and friends with guidelines for promoting safe food-handling practices for foods brought in from the outside. The resident handbook stated that nonperishable food was allowed in residents' rooms if it was put in a sealed container and labeled with name and date, and that nursing staff was notified. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, the trash compactor was not clean and the area around the trash compactor was littered with refuse. This is evidenced as follows. The trash compactor area was inspected on 04/10/2019 at 9:15 AM. The trash compactor area was littered with refuse, and the compactor door portal and the trash compactor shuttle room were soiled with a black build-up. The Director of Environmental Services stated in an interview on 04/10/2019 at 9:15 AM, that she will clean the compactor, compactor area, and compactor shuttle room. 10 NYCRR 415.14(h)

Inspectors wroteBased on observation, record review and interview during the recertification survey, the facility did not maintain an infection prevention and control program (IPCP) to prevent the development and transmission of disease and infection. Specifically, the facility did not insure the IPCP policies were reviewed annually. This is evidenced by: The following facility Infection Control Policies did not include documentation of an annual review: The Infection Prevention & Control Program Policy documented a review date of 10/18/17; The Antibiotic Stewardship Policy documented a review date of 10/18/17, 10/16/17; The facility Electronic Health Record (EMR) Nursing Guidelines Immunizations Policy did not include a date initiated or a date of review or revision. [...]