Wesley Court Health Center

Inspection findings

1. Jul 9, 2025 Health · 7 findings
   • Not serious Scope/severity D

     F0628 Resident Rights Deficiencies

     Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

     Corrected Jul 23, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0655 Resident Assessment and Care Planning Deficiencies

     Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

     Corrected Jul 23, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0804 Nutrition and Dietary Deficiencies

     Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

     Corrected Jul 23, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Jul 8, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0849 Administration Deficiencies

     Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

     Corrected Jul 23, 2025 · CMS health inspection

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Jul 9, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0914 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

     Corrected Jul 9, 2025 · CMS fire safety

2. Jun 5, 2024 Health · 10 findings
   • Not serious Scope/severity E Complaint

     F0655 Resident Assessment and Care Planning Deficiencies

     Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

     Corrected Jun 17, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0756 Pharmacy Service Deficiencies

     Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

     Corrected Jun 17, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0758 Pharmacy Service Deficiencies

     Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

     Corrected Jun 17, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0868 Administration Deficiencies

     Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

     Corrected Jun 17, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0947 Nursing and Physician Services Deficiencies

     Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

     Corrected Jun 17, 2024 · CMS health inspection

   • Not serious Scope/severity D

     K0293 Egress Deficiencies

     Have properly located and lighted "Exit" signs.

     Corrected Jun 30, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Jun 19, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Jun 17, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Jul 5, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0761 Miscellaneous Deficiencies

     To conduct inspection, testing and maintenance of fire doors by qualified individuals.

     Corrected Jun 30, 2024 · CMS fire safety

3. May 4, 2023 Health · 5 findings
   • Not serious Scope/severity E

     F0655 Resident Assessment and Care Planning Deficiencies

     Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

     Corrected May 31, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected May 31, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected May 31, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected May 31, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected May 31, 2023 · CMS health inspection

Owners and managers (as published by CMS)

• GORMAN, JOSEPH — corporate officer, NOT APPLICABLE, since 07/19/2022
• HARSHFIELD, NICHOLAS — corporate officer, NOT APPLICABLE, since 07/19/2022
• JANTZEN, JESSE — corporate director, NOT APPLICABLE, since 07/19/2022
• JANTZEN, JESSE — corporate officer, NOT APPLICABLE, since 07/19/2022
• POPE, ERIN — corporate officer, NOT APPLICABLE, since 07/25/2022
• RODGERS, CYNTHIA — w-2 managing employee, NOT APPLICABLE, since 07/19/2022
• LIFESPACE COMMUNITIES INC — 5% or greater direct ownership interest, 100%, since 07/19/2022
• LIFESPACE COMMUNITIES INC — operational/managerial control, NOT APPLICABLE, since 07/19/2022