(CLOSED) WESLEY HIGHLAND MANOR

The nursing staff is the most important part of what determines the quality of care and comfort of a resident in a nursing home. Government regulations set expectations on time spent with each resident based on the services being provided. The breakdown below lists the nursing types (RN, LPN, LVN, CNA) and a comparison of the reported and expected hours per resident per day.

Medicare determines quality of care ratings for nursing facilities by surveying several "quality measures", which are broken down into long-term and short-term stay residents, as well as if the action is preventive or if there is a deficiency in the quality of care. State averages for Tennessee are also provided for comparison purposes. Note: Figures below are averaged over the past nine months.

Long-Term Stay Preventive Actions

Long-Term Stay Deficiencies

Short-Term Stay Preventive Actions

Short-Term Stay Deficiencies

All Medicare and/or Medicaid certified nursing home must undergo health inspections on average once a year, but may be more frequent if the facility is peforming poorly. These inspections cover most aspects of life in a nursing home, and are broken down into deficiencies types, which including: Pharmacy Service, Administration, Resident Rights, Nutrition and Dietary, Resident Assessment, Environmental, and Mistreatment. Below are the list of deficiencies found by inspectors in the past few years along with the degree of harm and how many residents may have been affected. Note: The most recent health survey was on 05/21/2010.

Administration

1) Review the Work of Each Nurse Aide Every Year; or 2) Give Regular Training for the Nurse Aides. Inspection Date: 08/20/2008 Correction Date: 09/08/2008
Give or Get Lab Tests to Meet the Needs of Residents. Inspection Date: 10/28/2009 Correction Date: 11/13/2009
Keep Accurate and Appropriate Medical Records. Inspection Date: 10/28/2009 Correction Date: 11/13/2009
Give or Get Lab Tests to Meet the Needs of Residents. Inspection Date: 05/21/2010 Correction Date: 06/14/2010

Environmental

Have a Program to Keep Infection from Spreading. Inspection Date: 08/20/2008 Correction Date: 09/08/2008
Make Sure There is a Program to Prevent/Deal with Mice, Insects, or Other Pests. Inspection Date: 08/20/2008 Correction Date: 09/08/2008
Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents. Inspection Date: 05/21/2010 Correction Date: 06/14/2010
Have a Program to Keep Infection from Spreading. Inspection Date: 05/21/2010 Correction Date: 06/14/2010

Mistreatment

Keep Each Resident Free from Physical Restraints, Unless Needed for Medical Treatment. Inspection Date: 08/20/2008 Correction Date: 09/08/2008
Keep Each Resident Free from Physical Restraints, Unless Needed for Medical Treatment. Inspection Date: 05/21/2010 Correction Date: 06/14/2010
1) Hire Only People Who Have No Legal History of Abusing, Neglecting or Mistreating Residents; or 2) Report and Investigate Any Acts or Reports of Abuse, Neglect or Mistreatment of Residents. Inspection Date: 05/21/2010 Correction Date: 06/14/2010

Pharmacy Service

Properly Mark Drugs and Other Similar Products. Inspection Date: 08/20/2008 Correction Date: 09/08/2008
Keep the Rate of Medication Errors (Wrong Drug, Wrong Dose, Wrong Time) to Less Than 5%. Inspection Date: 10/28/2009 Correction Date: 11/13/2009
Keep the Rate of Medication Errors (Wrong Drug, Wrong Dose, Wrong Time) to Less Than 5%. Inspection Date: 05/21/2010 Correction Date: 06/14/2010
Properly Mark Drugs and Other Similar Products. Inspection Date: 05/21/2010 Correction Date: 06/14/2010

Quality Care

Give Professional Services That Follow Each Resident's Written Care Plan. Inspection Date: 08/20/2008 Correction Date: 09/08/2008
Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible. Inspection Date: 08/20/2008 Correction Date: 09/08/2008
Give Residents Proper Treatment to Prevent New Bed (Pressure) Sores or Heal Existing Bed Sores. Inspection Date: 08/20/2008 Correction Date: 09/08/2008
Use a Registered Nurse at Least 8 Hours a Day, 7 Days a Week. Inspection Date: 08/20/2008 Correction Date: 09/08/2008
Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible. Inspection Date: 10/28/2009 Correction Date: 11/13/2009
Make Sure That Each Resident Who Enters the Nursing Home Without a Catheter is Not Given a Catheter, Unless It is Necessary. Inspection Date: 10/28/2009 Correction Date: 11/13/2009
Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible. Inspection Date: 05/21/2010 Correction Date: 06/14/2010
Make Sure That Each Resident Who Enters the Nursing Home Without a Catheter is Not Given a Catheter, Unless It is Necessary. Inspection Date: 05/21/2010 Correction Date: 06/14/2010

Resident Assessment

1) Develop a Complete Care Plan Within 7 Days of Each Resident's Admission; 2) Prepare a Care Plan with the Care Team, Including the Primary Nurse, Doctor, Resident or Resident's Family or Representative; or 3) Check and Update the Care Plan. Inspection Date: 08/20/2008 Correction Date: 09/08/2008
Make Sure All Assessments Are Accurate, Coordinated by an Rn, Done by the Right Professional, and Are Signed by the Person Completing Them. Inspection Date: 05/21/2010 Correction Date: 06/14/2010
1) Develop a Complete Care Plan Within 7 Days of Each Resident's Admission; 2) Prepare a Care Plan with the Care Team, Including the Primary Nurse, Doctor, Resident or Resident's Family or Representative; or 3) Check and Update the Care Plan. Inspection Date: 05/21/2010 Correction Date: 06/14/2010

Resident Rights

Keep Each Resident's Personal and Medical Records Private and Confidential. Inspection Date: 05/21/2010 Correction Date: 06/14/2010
Provide Care in a Way That Keeps or Builds Each Resident's Dignity and Self Respect. Inspection Date: 05/21/2010 Correction Date: 06/14/2010

Nursing homes certified by Medicare and/or Medicaid are required to have fire safety inspections to meet Life Safety Code (LSC) standards. Below is a list of deficiencies that (Closed) Wesley Highland Manor had in recent fire safety inspections. This information can be used to see if all standards were met, the degree of harm, the number of residents affected, and the date when deficiencies were corrected. Note: The most recent fire safety survey was on 05/18/2010.

Automatic Sprinkler Systems

An Approved Automatic Sprinkler System Connected to the Fire Alarm System. Inspection Date: 08/18/2008 Correction Date: 09/26/2008
Portable Fire Extinguishers. Inspection Date: 08/18/2008 Correction Date: 09/26/2008

Building Service Equipment

Heating and Ventilation Systems That Have Been Properly Installed According to the Manufacturer's Instructions. Inspection Date: 08/18/2008 Correction Date: 09/26/2008
Properly Protected Cooking Facilities. Inspection Date: 08/18/2008 Correction Date: 09/26/2008
Properly Constructed Linen or Trash Chutes. Inspection Date: 10/26/2009 Correction Date: 11/13/2009
Heating and Ventilation Systems That Have Been Properly Installed According to the Manufacturer's Instructions. Inspection Date: 05/18/2010 Correction Date: 06/14/2010

Corridor Walls and Doors

Corridor and Hallway Doors That Block Smoke. Inspection Date: 08/18/2008 Correction Date: 09/26/2008

Electrical

Properly Installed Electrical Wiring and Equipment. Inspection Date: 08/18/2008 Correction Date: 09/26/2008
Properly Installed Electrical Wiring and Equipment. Inspection Date: 10/26/2009 Correction Date: 11/13/2009
Weekly Inspections and Monthly Testing of Generators. Inspection Date: 05/18/2010 Correction Date: 06/14/2010

Emergency Plans and Fire Drills

Record of Quarterly Fire Drills for Each Shift Under Varying Conditions. Inspection Date: 08/18/2008 Correction Date: 09/26/2008
Record of Quarterly Fire Drills for Each Shift Under Varying Conditions. Inspection Date: 05/18/2010 Correction Date: 06/14/2010

Exits and Egress

Exits That Are Accessible at All Times. Inspection Date: 08/18/2008 Correction Date: 09/26/2008
Exits That Are Accessible at All Times. Inspection Date: 05/18/2010 Correction Date: 06/14/2010

Fire Alarm Systems

A Fire Alarm System That Can Be Heard Throughout the Facility. Inspection Date: 08/18/2008 Correction Date: 09/26/2008
An Approved Installation, Maintenance and Testing Program for Fire Alarm Systems. Inspection Date: 08/18/2008 Correction Date: 09/26/2008
Properly Maintained Smoke Detectors. Inspection Date: 05/18/2010 Correction Date: 06/14/2010

Hazardous Area

Properly Installed Hallway Dispensers for Alcohol-Based Hand Rub. Inspection Date: 08/18/2008 Correction Date: 09/26/2008

Illumination and Emergency Power

Proper Backup Exit Lighting. Inspection Date: 08/18/2008 Correction Date: 09/26/2008

Smoke Compartmentation and Control

Smoke Barrier Doors That Can Resist Smoke for at Least 20 Minutes. Inspection Date: 10/26/2009 Correction Date: 11/13/2009

Smoking Regulations

Posted "No-Smoking" Signs in Areas Where Smoking is Not Permitted or Did Not Provide Ashtrays Where Smoking Was Allowed. Inspection Date: 08/18/2008 Correction Date: 09/26/2008