Wesley Park Centre

Based on observation, staff interview, and policy review, the facility failed to ensure kitchen staff were competent with dishwashing temperature checking procedures. The facility reported a census of 61 residents. Findings include:On 1/25/26 at 10:45 AM, an observation of three (3) dishwashing cycles revealed the rinse-water temperature gauge reached 171 degrees Fahrenheit (deg F) during all three observations. At 10:51 AM, Staff B, dishwasher, was asked to perform a dishwasher temperature check (procedure which uses a color-changing, temperature sensitive strip to confirm the dishwasher rinse-cycle water temperature reaches the required 180 deg F). Staff B stated he did not know how to perform the test because he never learned how to do it.At 11:03 AM, Staff B informed Staff E, dishwasher, that a dishwasher temperature check was requested. Staff E asked Staff B where the test strips were located. Staff B stated he did not know and both Staff B and Staff E searched for the strips. Staff E located the strips hanging in front of the dishwasher temperature check binder stored on the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and policy review, the facility failed to properly store food in the kitchen, failed to discard a can of damaged applesauce, failed to wear hairnets while in the kitchen, and failed to prevent food contamination by placing a non-food soup bowl in direct contact with a resident's food. The facility reported a census of 61 residents. Findings include:On 1/25/26 at 10:03 AM, Staff A, Cook, was observed in the main kitchen without a hair net.At 10:18 AM, Staff A was observed wearing a hair net.The following items were observed in the refrigerators during the initial kitchen tour: An unlabeled, undated, bowl of green, leafy itemsAn unlabeled, undated, bowl of mixed fruit-like itemsA partially uncovered pan of bacon dated 1/24/26A partially uncovered braised pork dated 1/23/26A partially uncovered, unlabeled, and undated pan of tube-shaped meat.An undated, opened box of lettuceAn unlabeled, clear sealable bag of shredded, orange substanceAn undated, unlabeled pan of brown crust with a yellow topping The following items were observed in the freezer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, clinical record review, resident and staff interviews, and policy review, the facility failed to provide appropriate treatment and services to prevent a urinary tract infection for 1 of 1 resident (#56). The facility reported a census of 61 residents. Findings include:The Minimum Data Set (MDS) Assessment for Resident #56 dated 11/20/25 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated moderately impaired cognition. It included diagnoses of coronary artery disease (disease of the heart arteries), high blood pressure, a stroke, and a urinary tract infection (UTI). It indicated he was independent with rolling from left-to-right in bed, required setup assistance with eating and oral and personal hygiene, required moderate assistance with upper body dressing and sit-to-lying and lying-to-sitting, and was dependent with all other Activities of Daily Living (ADLs) and mobility. It also indicated he had a UTI within the previous 30 days.A laboratory report dated 11/01/25 confirmed the resident's urine specimen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, and resident and staff interviews, the facility failed to ensure hot foods were held at an appetizing temperature for 1 of 1 meal observed and for 2 of 24 residents reviewed (Residents #48 and #163). The facility reported a census of 65 residents. Findings include: 1. An observation prior to the start of the lunch service on 1/22/25, Staff A [NAME] obtained the following temperatures: grilled ham and cheese sandwiches 151.6 F at 11:53 a.m. meat sauce 162.6 F at 11:56 a.m. noodles 172.6 F at 11:59 a.m. mashed potatoes 160.4 F at 11:58 a.m. pureed vegetables 132.2 at 12:01 p.m. Staff A did not heat up the pureed vegetables prior to the start of service. Staff A served the first tray at 12:10 p.m. and the last tray at 12:55 p.m. Immediately after staff served the last tray, the State Agency requested a test tray. The State Agency obtained the following temperatures with a facility provided thermometer. The Certified Dietary Manager was present during this process. grilled ham…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, policy review, and staff interview, the facility failed to ensure staff prepared food under sanitary conditions for 2 of 2 kitchen observations. The facility reported a census of 65 residents. Findings include: During the initial kitchen tour on 1/21/25 at 9:46 a.m., dust particles hung from 8 of 8 fire suppression spigots. Two string-like particles of dust, approximately 2 inches in length, hung down from the spigot on the left side of the stove hood, located directly above a pot of boiling food. During a follow-up visit to the kitchen on 1/22/25 at 10:59 a.m., dust remained on the spigots of the fire suppression system. The metal surface behind the tilt skillet also contained a thick layer of dust particles. The undated facility Night [NAME] Closing List and Morning [NAME] Checklist did not include direction for staff to clean the fire suppression system spigots. The facility policy Food Safety, revised July 2024, directed staff to monitor the risk of contamination during cooking, cooling, holding, and reheating. On 1/23/24 at 9:35 a.m., the Certified Dietary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident and staff interviews, the facility failed to provide dignity with care by turning off the call light and leaving the room without ensuring the resident's needs were met for 1 of 6 residents reviewed for dignity (Resident #54). The facility reported a census of 65 residents. Findings include: The admission Minimum Data Set (MDS) dated [DATE] for Resident #54 revealed a diagnosis of a Stroke with aphasia (difficulty speaking) and right sided hemiplegia (paralysis), Diabetes Mellitus, and required the assistance of 2 for repositioning in bed. The Brief Interview for Mental Status (BIMS) score was 14 which suggested an intact cognition. The Care Plan for Resident #54 directed staff to allow adequate time to respond when communicating, and repeat if necessary or request clarification from the resident to ensure understanding and required the assistance of 2 staff for bed mobility, toileting and transfers. During an observation on 1/21/25 at 3:39 PM Resident #54 was in a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, and staff interviews, the facility failed to ensure water temperatures at points of delivery did not exceed safe maximum temperatures for 4 of 6 resident room sinks and for 1 of 3 shower rooms. The facility reported a census of 65 residents. Findings Include: Temperature readings obtained by the State Agency on 1/22/25 revealed the following concerns: 8:15 a.m. room [ROOM NUMBER] bathroom sink 127.7 F(Fahrenheit) 8:20 a.m. room [ROOM NUMBER] bathroom sink 126.4 F 8:26 a.m. South Sunset Shower room [ROOM NUMBER].4 F 8:38 a.m. room [ROOM NUMBER] bathroom sink 125.4 F 8:42 a.m. room [ROOM NUMBER] bathroom sink 121.6 F Temperature readings obtained by Staff B Maintenance Staff on 1/22/25 revealed the following concerns: 8:49 a.m. room [ROOM NUMBER] bathroom sink 125.2 F. Staff B stated that's not good while he obtained this temperature. 8:52 a.m. room [ROOM NUMBER] bathroom sink 124.5 F. After the temperature measurements, Staff B stated water temps should be less than 120 F and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff interview, resident interview and policy review the facility failed to ensure resident call light within reach for 1 of 21 residents reviewed (Resident #22). The facility reported the census is 64. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #22 documented a Brief Interview of Mental Status (BIMS) of 8 indicating moderate cognitive impairment. The MDS documented diagnosis to include heart disease, renal disease, dementia, anxiety and stroke or transient ischemic attack. The Care Plan included intervention initiated 3/19/24 for Resident #22, documented resident often times places call light pendant in small places and unable to recall location. Resident #22 does have wall pendant in place and able to verbalize needs to staff. Care plan focus initiated 1/15/24 included, Resident #22 is at risk for falls related to dementia, hallucinations, insomnia, and possible medication side effects. Interventions included Resident #22 encouraged to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.