Wesley Enhanced Living at Stapeley

In the surveyor’s words

From the most serious findings on record at Wesley Enhanced Living at Stapeley, in the surveyor’s own words.

• Actual harm, isolatedF689Nov 4, 2024

  Based on review of clinical record, review of facility documentation and interview with staff, it was determined that the facility failed to ensure that one of six residents reviewed receive the required assistance via mechanical lift during a bed to chair transfer. This failure resulted in actual harm to Resident R1 whose left leg got twisted during transfer and sustained a fracture of the left femur (thigh bone). (Resident R1) Findings include: Review of facility policy 'Using a Mechanical Lifting Machine,' revised July 2017, states the following: 4. Prepare the environment: a. clear an unobstructed path for the lift machine; b. ensure there is enough room to pivot; c. position the lift near the receiving surface; and d. place lift at correct height. […]

• Actual harm, isolatedF689Nov 15, 2022

  Based on a review of clinical records, review of hospital documentation and staff interviews, it was determined that the facility failed to ensure adequate supervision during a transfer for one of two residents reviewed for falls (Resident R80). This failure resulted in actual harm to Resident R80 who did not receive the appropriate level of assistance during a transfer from bed to wheelchair and sustained displaced spiral fractures of the right distal tibial and fibular shafts. […]

• No harm, potential for more than minimal, widespreadF812Sep 28, 2023

  Based on review of facility policy, observations, and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings include: Review of facility policy titled, Dish Machine Temperature Log, dated 2017, indicated that dishwashing staff will monitor and record dish machine temperatures to assure proper sanitizing of dishes. Staff will record dish machine temperatures for the wash and rinse cycles at each meal. Review of facility policy titled, Food Labeling Policy, indicated that all food items need to be labeled and rotated to ensure proper food safety . […]

• No harm, potential for more than minimal, patternF689May 7, 2026

  Based on record review, facility policies, facility documents, observations, and staff interviews, it was determined that the facility failed to ensure the safety and adequate supervision and ensure that safety devices were in place for five of six residents reviewed for risk of wandering and elopement. (Residents 122, R21, and R39).Findings include: Review of facility policy titled Elopement of a Resident, last revised 12/17/2025, outlines procedures to ensure resident safety and prevent elopement, particularly for residents with dementia or cognitive impairment. The policy requires elopement risk assessments upon admission, family interviews, resident photographs in the medical record, Wander Guards for at-risk residents, and individualized care plans to address wandering behaviors. […]

• No harm, potential for more than minimal, patternF880May 7, 2026

  Based on policy review and record review, the facility failed to implement an effective and comprehensive water management program necessary to identify, monitor, control, and reduce hazardous conditions supporting the growth and spread of Legionella within the facility water system and failed to ensure proper infection control practices during the administration of eye drops for one of one resident observed. (Resident R101)Findings inlcude: Review of the CDC (Center for Disease Control and Prevention- a major public health agency in the United States that works to: Monitor and track diseases (like flu, COVID-19, etc.) ,Prevent outbreaks and health threats ,Provide health guidelines and research ,and Respond to emergencies (pandemics, natural disasters, bioterrorism) recommends that… […]