Inspection Reports for
Wesley Health Care Center Inc
131 Lawrence Street, Saratoga Springs, NY, 12866
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Inspection Report — Nov 19, 2024
Certification/complaint State
Date: Nov 19, 2024
Visit Reason
State-compiled facility profile showing 10 inspections from 2022 to 2026 with citation and complaint history including enforcement actions and fines.
Complaint Details
The state logged 168 complaints about this facility; 11 led to on-site inspections. Five citations resulted from those complaints.
Findings
Across 10 inspections, 7 had no citations while 3 inspections resulted in 36 citations total, including 12 standard health and 24 Life Safety Code citations. The facility had 168 complaints with 11 on-site inspections and 1 enforcement action with fines recorded.
Citations (21)
Standard Health Citation — quality of care: Activities did not meet interests or needs of each resident.
Standard Health Citation — quality of care: Care plans were not timely revised as required.
Standard Health Citation — quality of care: Food procurement, storage, preparation, and serving were not sanitary.
Standard Health Citation — quality of care: Infection prevention and control measures were inadequate.
Standard Health Citation — quality of care: PASARR screening for mental and intellectual disabilities was deficient.
Standard Health Citation — quality of care: Resident records lacked identifiable information as required.
Standard Health Citation — quality of care: Resident rights were not fully exercised or protected.
Standard Health Citation — quality of care: Respiratory/tracheostomy care and suctioning were deficient.
Standard Health Citation — quality of care: Providers failed to notify as required.
Life Safety Code Citation — NFPA requirements: Discharge from exits was not compliant.
Life Safety Code Citation — NFPA requirements: Essential electrical systems were deficient.
Life Safety Code Citation — NFPA requirements: Other electrical systems were deficient.
Life Safety Code Citation — NFPA requirements: Emergency lighting was inadequate.
Life Safety Code Citation — NFPA requirements: Fire alarm system testing and maintenance were deficient.
Life Safety Code Citation — NFPA requirements: Plan based on all hazards risk assessment was inadequate.
Life Safety Code Citation — NFPA requirements: Portable fire extinguishers were not properly maintained.
Life Safety Code Citation — NFPA requirements: Sprinkler system maintenance and testing were deficient.
Life Safety Code Citation — NFPA requirements: Subdivision of building spaces with smoke barriers was deficient.
Standard Health Citation — quality of care: Radiology/diagnostic services ordered but results notification was deficient.
Standard Health Citation — quality of care: Treatment/services to prevent or heal pressure ulcers were deficient.
Standard Health Citation — quality of care: Failure to notify of changes such as injury, decline, or room changes.
Report Facts
Inspections on page: 10
Total violations/deficiencies cited: 36
Inspections with violations: 3
Inspections without violations: 7
Complaints total: 168
On-site complaint inspections: 11
Citations from complaints: 5
Enforcement actions: 1
Total fines: 10000
Inspection Report — Nov 19, 2024
Annual Inspection CMS
Date: Nov 19, 2024
Visit Reason
The inspection was a recertification survey and abbreviated survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, missing preadmission screenings, incomplete care plan reviews, inadequate respiratory care and oxygen administration, insufficient activity programming, poor food service sanitation, incomplete medical record documentation, and infection prevention and control failures during a COVID-19 outbreak.
Citations (8)
F 0550: The facility failed to ensure residents were treated with dignity and respect, including timely assistance with toileting and meal consumption for 2 residents.
F 0645: The facility did not ensure a Preadmission Screening and Resident Review (PASARR) was completed for 1 resident prior to admission.
F 0657: The facility failed to review and revise the Comprehensive Care Plan for respiratory therapy for 1 resident when respiratory status changed.
F 0679: The facility did not provide activities that met the preferences and cognitive abilities of 1 resident.
F 0695: The facility failed to ensure oxygen tubing was dated and labeled when changed and supplemental oxygen was provided as ordered for 3 residents.
F 0812: The facility did not ensure food was stored, prepared, distributed, or served in accordance with professional standards; multiple resident kitchenettes were dirty and open containers were unlabeled.
F 0842: The facility failed to maintain accurate medical records documenting oxygen use and verification every four hours for 1 resident.
F 0880: The facility did not implement an effective infection prevention and control program during a COVID-19 outbreak, including cohorting COVID positive and negative residents together, open doors to isolation rooms, contaminated mechanical lifts, and inconsistent PPE use.
Report Facts
Residents reviewed: 39
Residents affected by dignity deficiency: 2
Residents affected by PASARR deficiency: 1
Residents affected by care plan review deficiency: 1
Residents affected by activity deficiency: 1
Residents affected by oxygen tubing deficiency: 3
Residents affected by food service sanitation deficiency: 8
Residents affected by medical record documentation deficiency: 1
Residents affected by infection control deficiency: 174
Staff positive for COVID-19: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #4 | Named in dignity and activity deficiencies interviews | |
| Licensed Practical Nurse #1 | Named in dignity deficiency interview and apology | |
| Director of Nursing #1 | Director of Nursing | Named in dignity, activity, oxygen, and infection control interviews |
| Assistant Director of Nursing #1 | Assistant Director of Nursing | Named in dignity deficiency interview |
| Admissions Coordinator #1 | Named in PASARR deficiency interview | |
| Administrator #1 | Administrator | Named in PASARR deficiency interview |
| Registered Nurse #2 | Named in oxygen administration deficiency interviews | |
| Registered Nurse #1 | Named in oxygen tubing labeling deficiency interview | |
| Licensed Practical Nurse #2 | Named in oxygen tubing labeling deficiency interview | |
| Licensed Practical Nurse #3 | Named in oxygen tubing labeling deficiency interview | |
| Life Enrichment director #1 | Named in activity deficiency interview | |
| Nutritional Services Manager #1 | Named in food service sanitation interview | |
| Director of Environmental Services #1 | Named in food service sanitation interview | |
| Infection Preventionist #1 | Named in infection control deficiency interview | |
| Certified Nurse Aide #3 | Observed with improper mask use | |
| Licensed Practical Nurse #4 | Observed with improper PPE use |
Inspection Report — Aug 11, 2023
Abbreviated Survey CMS
Date: Aug 11, 2023
Visit Reason
The visit was conducted as an abbreviated survey to assess compliance with regulatory requirements related to pressure ulcer care and physician notification of test results.
Findings
The facility failed to ensure appropriate pressure ulcer care and prevention for one resident, including lack of weekly wound assessments and incomplete care planning. Additionally, the facility did not promptly notify the physician of abnormal x-ray results for the same resident.
Citations (2)
F 0686: The facility did not implement weekly pressure ulcer assessments or develop a care plan with treatment strategies for a resident with stage 2 pressure ulcers on the coccyx/buttocks, resulting in inadequate wound monitoring and documentation.
F 0777: The facility failed to promptly notify the ordering physician of x-ray results indicating a new fracture for a resident, with notification delayed from 5/21/2019 to 6/6/2019.
Report Facts
Residents affected: 1
Dates of wound measurements: 0.8
Dates of wound measurements: 0.5
Dates of wound measurements: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON #1 | Director of Nursing | Named in wound assessment and physician notification findings |
| DON #2 | Former Director of Nursing | Named in wound tracking and meetings |
| ADON | Assistant Director of Nursing | Named in wound care training and policy implementation |
| MD #1 | Physician | Named in delayed notification of x-ray results |
| MD #3 | Medical Director | Provided expert opinion on wound healing and notification |
Inspection Report — Oct 5, 2021
Annual Inspection CMS
Date: Oct 5, 2021
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory standards for nursing home operations, including medication regimen review, food safety, pest control, and policies regarding food brought by visitors.
Findings
The facility was found deficient in several areas including lack of a complete policy for monthly medication regimen review, improper food service safety practices including inadequate sanitizer testing and dishwashing machine operation, failure to adhere to policies on labeling and safe handling of food brought by visitors, and an ineffective pest control program evidenced by fruit fly infestations in the kitchen.
Citations (4)
F 0756: The facility did not ensure a policy was developed for monthly medication regimen review that included steps and timeframes for urgent irregularity reporting and response.
F 0812: The facility did not provide an accurate test kit for sanitizer concentration and the dishwashing machine was not operating according to manufacturer instructions.
F 0813: The facility did not adhere to its policy on labeling and safe handling of foods brought to residents by family and visitors, and did not provide safe food handling information to families.
F 0925: The facility did not maintain an effective pest control program as evidenced by sightings of flying insects in the main kitchen and soiled drain areas.
Report Facts
Dishwashing machine final rinse water pressure: 12
Sanitizer dilution range: 200
Sanitizer dilution range: 400
Fruit fly activity dates: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Facility Administrator | Interviewed regarding medication regimen review policy and food labeling procedures | |
| Dining Services Director | Interviewed regarding dishwashing machine operation and pest control observations | |
| Registered Nurse #1 | Interviewed regarding food labeling practices | |
| Registered Nurse #2 | Interviewed regarding food brought by family members | |
| Director of Environmental Services | Interviewed regarding pest control awareness | |
| Director of Maintenance | Interviewed regarding cleaning of ice machine condensate drain |
Inspection Report — Apr 17, 2019
Annual Inspection CMS
Date: Apr 17, 2019
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for the nursing home.
Findings
The facility was found deficient in providing written summaries of baseline care plans to residents and their representatives, lacked a policy with time frames for monthly medication regimen reviews, did not have a policy for safe use and storage of foods brought in by visitors, failed to properly dispose of garbage and refuse, and did not maintain an infection prevention and control program with annually reviewed policies.
Citations (5)
F 0655: The facility did not provide written summaries of baseline care plans to 4 of 20 residents and their representatives within 48 hours of admission.
F 0756: The facility lacked a policy with established time frames for steps in the monthly Medication Regimen Review process.
F 0813: The facility did not have a policy regarding safe use and storage of foods brought in by family and visitors, including education on safe food handling.
F 0814: The facility did not properly dispose of garbage and refuse; the trash compactor area was littered and soiled.
F 0880: The facility did not maintain an infection prevention and control program with annually reviewed policies as required.
Report Facts
Residents reviewed: 20
Residents affected: 4
Date of inspection: Apr 17, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding baseline care plan summaries and inability to find documentation | |
| Registered Nurse #1 | RN | Interviewed about methods to complete 48-hour care plan |
| Administrator | Interviewed regarding lack of time frames in Medication Regimen Review process | |
| Director of Pharmacy #1 | Interviewed about monthly medication chart reviews and follow-up on pharmacy recommendations | |
| Director of Social Services | Interviewed about lack of handout for family and visitors on safe food handling | |
| Chief Registered Dietitian | RD | Interviewed about food brought in from outside and lack of education on safe food handling |
| Food Service Manager | FSD | Interviewed about food handling policies and plans to provide handouts |
| Director of Environmental Services | Interviewed about cleaning trash compactor area | |
| Infection Control Preventionist | ICP | Interviewed about infection control policy reviews |
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