Deficiencies (last 5 years)
Deficiencies (over 5 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
30% worse than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
51 residents
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 51
Deficiencies: 7
Apr 24, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, food service, infection control, and equipment maintenance at Wesley Glen Health Services Corp.
Findings
The facility was found deficient in multiple areas including incomplete care plans for pain management and infection precautions, inadequate fall prevention interventions, improper food temperature and handling, failure to honor resident food preferences, unsanitary kitchen conditions, improper wound care practices, lack of enhanced barrier precautions for certain residents, and unsafe patient care equipment maintenance.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure residents had complete care plans for pain management, enhanced barrier precautions, and acute infection. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure fall interventions were in place for a resident at high risk for falls. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food was served at a palatable and safe temperature. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to honor resident food requests or preferences. | Level of Harm - Minimal harm or potential for actual harm |
| Did not maintain a clean sanitary kitchen, store food safely, and serve food in a sanitary manner. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement an infection prevention and control program including proper wound care and enhanced barrier precautions. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to keep essential patient care equipment working safely, including a loose grab bar in the spa room. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 51
Residents affected: 2
Residents affected: 1
Residents affected: 51
Residents affected: 2
Residents affected: 8
Residents affected: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #321 | Registered Nurse | Named in wound care treatment deficiency for not disinfecting scissors and allowing wound to touch dirty surface |
| Director of Nursing | Director of Nursing (DON) | Confirmed deficiencies related to care plans and enhanced barrier precautions |
| LPN #233 | Licensed Practical Nurse | Confirmed lack of fall intervention (perimeter mattress) for Resident #40 |
| DSD #276 | Dining Services Director | Provided information on food temperature standards and confirmed food temperature deficiencies |
| Dining Operations Manager #290 | Dining Operations Manager | Verified failures to honor resident food preferences |
| Maintenance Technician #444 | Maintenance Technician | Verified loose grab bar in spa room |
| Maintenance Director #450 | Maintenance Director | Confirmed grab bar was broken and discussed repair process |
| RN #265 | Registered Nurse | Confirmed lack of enhanced barrier precautions for Resident #155 |
| Certified Nursing Assistant #227 | Certified Nursing Assistant | Reported resident complaints about food temperature |
| Activities Assistant #460 | Activities Assistant | Observed serving food without gloves and poor hand hygiene |
Inspection Report
Plan of Correction
Deficiencies: 0
May 20, 2024
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction related to the nursing home regulatory inspection.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 4
Jun 6, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to notify responsible parties of changes in a resident's condition, failure to timely report an injury of unknown origin, failure to investigate the injury, and failure to ensure fall interventions for residents at risk of falls.
Findings
The facility failed to notify the responsible party of changes in Resident #90's condition, failed to timely report and investigate an injury of unknown origin for Resident #90, and failed to ensure fall interventions were in place for Resident #100, who was at risk for falls. The facility census was 46.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00143042.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to notify the responsible party of changes in a resident's condition affecting Resident #90. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely report an injury of unknown origin to the State Survey Agency for Resident #90. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to investigate an injury of unknown origin for Resident #90. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure fall interventions were in place for Resident #100 at risk for falls. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 46
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Practitioner #640 | Certified Nurse Practitioner | Named in progress notes regarding Resident #90's unapproximated surgical wound and communication with nursing and Director of Nursing |
| Physician #630 | Physician | Named in progress notes related to Resident #90's right lower leg pain and X-ray orders |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding lack of family notification and injury reporting for Resident #90 and fall intervention for Resident #100 |
| Hospice Case Manager Registered Nurse #600 | Hospice Case Manager Registered Nurse | Interviewed regarding hospice visits and observations of Resident #90's leg condition |
| Activities Worker #590 | Activities Worker | Interviewed regarding absence of dycem on Resident #100's wheelchair |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 1
Mar 30, 2023
Visit Reason
The inspection was conducted due to complaints regarding delayed call light response times affecting residents' care and safety.
Findings
The facility failed to ensure timely response to call lights, affecting two residents (#19 and #58) out of three reviewed. Call light response times ranged from 16 to 53 minutes, exceeding the facility's expected 15-minute response time, leading to resident dissatisfaction and staff disciplinary actions.
Complaint Details
This deficiency represents non-compliance in Master Complaint Number OH00141162, and Complaint Numbers OH00140722, and OH00137052.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure call lights were answered timely, affecting residents #19 and #58. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Call light response time: 16
Call light response time: 27
Call light response time: 29
Call light response time: 16
Call light response time: 53
Facility census: 56
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Verified call light response times were a concern and described facility's corrective actions |
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 5
Sep 16, 2022
Visit Reason
The inspection was conducted due to complaints and allegations regarding failure to timely report and thoroughly investigate an allegation of sexual abuse, failure to administer medications as ordered, failure to maintain infection control protocols, and failure to administer pneumonia vaccine to a resident.
Findings
The facility failed to timely report an allegation of sexual abuse, failed to complete a thorough investigation of the abuse allegation, failed to administer medications as ordered for two residents, failed to maintain proper infection control protocols including PPE use during quarantine, and failed to administer a pneumonia vaccine to a resident. These deficiencies affected multiple residents and had potential for harm.
Complaint Details
The complaint investigation focused on allegations of sexual abuse involving Resident #162 and failure to respond appropriately to the allegation. The facility failed to timely report the abuse to the Ohio Department of Health and failed to conduct a thorough investigation including physical assessment and documentation. The complaint also included medication administration issues, infection control failures, and vaccination administration failures.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to timely report an allegation of sexual abuse to the State Survey Agency. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete a thorough investigation regarding a resident's allegation of sexual abuse, including lack of physical assessment and documentation. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medications were administered as physician ordered, including delays in pain and anxiety medications and inconsistent administration of allergy medication. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain infection control protocols and wear appropriate PPE in resident rooms under quarantine, risking spread of COVID-19. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to administer a pneumonia vaccine to a resident despite consent and policy requirements. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 45
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Quarantine duration: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Confirmed failure to notify Ohio Department of Health of abuse allegation and failure to complete physical assessments | |
| Director of Nursing | DON | Confirmed failure to notify Ohio Department of Health, failure to complete physical assessments, unawareness of medication delays, and infection control protocol failures |
| Nurse Practitioner #200 | NP | Interviewed regarding medication delay for Resident #159 |
| Registered Nurse #20 | RN | Interviewed regarding admission assessment and medication verification |
| Registered Nurse #21 | RN | Completed intake assessment for Resident #159 and interviewed about medication administration |
| State Tested Nursing Aide #42 | STNA | Observed removing mask in Resident #160's room during quarantine |
| State Tested Nursing Aide #39 | STNA | Interviewed about PPE use and isolation box contents |
Inspection Report
Routine
Census: 41
Deficiencies: 13
Feb 20, 2020
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, rights, safety, medication management, abuse prevention, care planning, and other quality of care issues at Wesley Glen Health Services Corp.
Findings
The facility was found deficient in multiple areas including failure to provide resident-preferred showers, failure to obtain proper authorization for resident funds, failure to notify physicians of changes in condition, failure to maintain resident privacy during care, failure to investigate and report injuries of unknown origin, failure to complete required Minimum Data Set (MDS) assessments, failure to develop and implement comprehensive care plans, failure to provide appropriate respiratory care, failure to ensure residents wore ordered splints, failure to provide timely assistance to prevent falls resulting in injury, and failure to support diagnoses for psychotropic medication use.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 12
Level of Harm - Potential for minimal harm: 1
Level of Harm - Actual harm: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to provide weekly showers per resident preference affecting Resident #42. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to obtain proper authorization to establish a personal care needs account for Resident #29. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to notify physician of Resident #18's low blood pressures and holding of blood pressure medication. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide privacy during pressure ulcer dressing change for Resident #8. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement abuse policy and conduct thorough investigation for injury of unknown origin for Resident #7. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely report injury of unknown origin for Resident #7 to State Survey Agency. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to conduct thorough investigation for injury of unknown origin for Resident #7. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to conduct and transmit discharge Minimum Data Set (MDS) assessments for Residents #1, #2, and #3. | Level of Harm - Potential for minimal harm |
| Failed to develop and implement complete care plans addressing falls and medication use for Residents #18, #27, #37, and #42. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate respiratory care and timely response to acute change for Resident #11; failed to timely identify and assess non-pressure skin breakdown for Resident #37. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure Resident #19 wore ordered left hand and elbow splints as prescribed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide timely assistance with toileting to prevent fall resulting in fracture for Resident #27. | Level of Harm - Actual harm |
| Failed to have supporting diagnoses for Residents #13 and #42 on psychotropic medications; failed to implement gradual dose reductions and limit PRN use. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents at risk for falls: 26
Residents reviewed for care plans: 17
Residents reviewed for abuse: 2
Residents reviewed for unnecessary medications: 6
Residents reviewed for quality of care: 14
Residents reviewed for skin conditions: 5
Residents reviewed for discharges: 6
Days Resident #11 not weighed as ordered: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Confirmed Resident #42 did not receive scheduled showers; verified failure to notify physician of Resident #18's low blood pressure; confirmed failure to investigate injury of unknown origin for Resident #7; confirmed lack of fall care plan for Resident #27; confirmed Resident #13 lacked diagnosis for antipsychotic use; confirmed Resident #42 lacked diagnosis for antipsychotic use; confirmed Resident #27 fall and toileting incident. |
| John Smith | Administrator | Verified failure to obtain authorization for Resident #29's personal care needs account; verified failure to investigate and report injury of unknown origin for Resident #7. |
| LPN #44 | Licensed Practical Nurse | Observed Resident #11's oxygen concentrator was plugged in but not set; confirmed Resident #19 was supposed to wear splints; assisted in Resident #11 assessment. |
| LPN #48 | Licensed Practical Nurse | Observed failure to provide privacy during pressure ulcer dressing change for Resident #8. |
| LPN #55 | Licensed Practical Nurse | Verified Resident #7 bruising incident; verified Resident #37's bed not in lowest position; verified Resident #19 splint use. |
| Scheduler #89 | State Tested Nursing Assistant | Reported Resident #11 oxygen not on; delayed notifying nurse of Resident #11 shortness of breath. |
| STNA #31 | State Tested Nursing Assistant | Verified Resident #19 splint use and laundry of soiled splint. |
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