Wesley Palms

Allegation investigated: Unqualified staff administering medication(s) to resident(s).

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced visit to initiate a complaint investigation and deliver findings regarding the above-mentioned allegation. LPA identified themselves and met with Executive Director Justin Weber to discuss the purpose of the visit and elements of the complaint. On 07/16/2026, it was alleged that unqualified staff were administering medication(s) to resident(s). More specifically, the allegation stated that a particular staff member (S1) administered medications to a resident (R1) during an unknown shift time or day. The reporting party stated they believed S1 was not qualified due to S1 wearing a Certified Nursing Assistant(CNA) badge rather than a licensed nurse badge.The Department’s investigation consisted of interviews and records review. [Cont. on LIC 9099-C] Unsubstantiated [Cont. from LIC-9099] Regarding the allegation, interviews with staff consistently reported that only certified staff and licensed nurses administer medications, including care giving staff. Staff who were not medication certified reported performing only Activities of Daily Living (ADLs) and stated they do not administer medications. Supervisory staff reported that licensed nurse coverage is maintained on all shifts, including weekends, and stated they had not observed any unqualified staff performing medication duties. Qualified medication staff confirmed they completed required training, including examination, shadowing, online training and a final exam competency review, and stated they had not witnessed inappropriate or improper medication administration by any staff. Records review of the staff roster showed a combination of certified nursing assistants (CNA), memory care assistants, caregivers, licensed vocational nurses (LVN), and registered nurses (RN) assigned throughout the facility. Job descriptions for caregivers and memory care assistants included ADLs and general care duties only, with no medication related tasks. CNA job descriptions included medication management responsibilities, while LVN and RN job descriptions outlined medication administration and nursing interventions. Staffing schedules from June through July 2026 demonstrated that all shifts in both the main building and memory care areas included either licensed nurses or medication administration qualified staff, including weekends. Training records, including RCFE medication orientation exam results, confirmed that staff responsible for medication administration had completed required qualifications. Additionally, records review revealed that S1 had completed the facility’s medication qualification process and possessed the necessary certification to administer medications. Based on interviews and records review, the preponderance of evidence standard has not been met, therefore the above allegation is found to be unsubstantiated. An exit interview was conducted with Executive Director Justin Weber and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided. Their signature confirms receipts of these documents.the state’s words, verbatim · CDSS document, Jul 22, 2026 · control 08-AS-20260716090539

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Justin Weber. According to the facility’s license, the facility has a maximum capacity of 511 non-ambulatory residents, of which 370 may be bedridden with a hospice waiver for 15. The facility has one large main building, multiple cottages and a delayed egress memory care unit. LPA toured the interior and exterior of the facility and inspected multiple rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Water temperature in residents rooms were all compliant. The facility does have a pool with appropriate locked fencing. LPA toured and observed the commercial kitchen and walk-in freezer/refrigerator. The kitchen was clean, organized and sanitary. Cooking/dining equipment and utensils were present. There was sufficient perishable food and at least two weeks worth of non-perishable food. LPA observed multiple medication rooms and first aids were complete and readily accessible. Medications were labeled, as required, and stored in locked medication carts. Resident records contained the required documentation. Staff records contained the required documentation. Per Executive Director, no firearms or ammunition are kept at the facility. Fire extinguishers were readily accessible on each floor. No deficiencies were cited on todays visit. An exit interview was conducted with Executive Director Justin Webb, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided to during the visit.the state’s words, verbatim · CDSS document, Feb 19, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Iby Strong, conducted an unannounced Case Management Visit. LPA met with Executive Director Justin Webber, and we discussed the purpose of the visit. Today's visit is in response to the self reported death of Resident 1 (R1 - see LIC811 Confidential Names List). R1 passed away on 3/11/2025. LPA conducted a wellness check at the facility, and no health or safety issues were identified. Residents observed appeared appropriate for the facility. Additional facility records were obtained on this date regarding R1's care. No deficiencies were cited or observed on this date. An exit interview was conducted. The Licensee was provided a copy of their appeal rights (LIC9058 03/22), along with a copy of this report.the state’s words, verbatim · CDSS document, Mar 14, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Justin Webber. According to the facility’s license, the facility has a maximum capacity of 511 non-ambulatory residents, of which 370 may be bedridden with a hospice waiver for 15. The facility has one large main building, multiple cottages and a delayed egress memory care unit. LPA toured the interior and exterior of the facility and inspected multiple rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Water temperature in residents rooms were measured all between 110 degrees F to 117 degrees F. The facility does have a pool with appropriate locked fencing. LPA tested multiple resident call buttons and verified signal system was in working order. LPA toured and observed the commercial kitchen and walk-in freezer/refrigerator. The kitchen was clean, organized and sanitary. Cooking/dining equipment and utensils were present. There was sufficient perishable food and at least two weeks worth of non-perishable food. LPA observed multiple medication rooms and first aids were complete and readily accessible. Medications were labeled, as required, and stored in locked medication carts. Resident records contained the required documentation. Staff records contained the required documentation. LPA reviewed care staff first aid refresher training's within the facility training system. Per Executive Director, no firearms or ammunition are kept at the facility. Fire extinguishers were readily accessible on each floor. No deficiencies were cited on todays visit. An exit interview was conducted with Executive Director Justin Webb, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided to during the visit.the state’s words, verbatim · CDSS document, Feb 11, 2025

Allegation investigated: Licensee did not provide residents with reappraisals Staff did not assist residents with incontinence care

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to continue an investigation on the above allegations. LPA identified herself and discussed the purpose of the visit with Director of Human Resources Claudia Rubio. On June 8, 2022, Community Care Licensing (CCL) received a complaint alleging licensee did not provide residents with reappraisals and staff did not assist residents with incontinence care. During the investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. According to the allegation, the licensee did not provide Resident 1 (R1) and Resident 2 (R2) with reappraisals after aggressive behaviors. Based on R1’s Physician Report dated May 28, 2021, R1 is known to have aggressive behaviors. Additionally, R1’s needs plan states that R1 can become easily agitated and is known to have physical aggression. Unsubstantiated Based on R2’s needs plan, R2 can be occasionally aggressive toward staff. Interview with staff present during the time in question revealed R1 and R2’s behaviors were known and did not require additional reappraisal. Interview with Director of Health Services revealed that residents in assisted living and memory care receive quarterly reappraisals and if there a change in condition a medical reappraisal would be provided immediately. Records corroborated that both R1 and R2’s behaviors were known prior to report. Interview with outside source did not corroborate that residents are not provided with reappraisals. . It was also alleged that staff were not providing incontinence care for residents in memory care. Interview with multiple staff revealed that residents who are incontinent are changed every two hours by care staff. Interview with Memory Care Manager revealed that all residents are checked on every two hours. Interview with outside source could not corroborate that residents in memory care are not provided timely incontinence care. Interview with residents in care corroborated that residents are checked for incontinence needs multiple times per day. Based on LPA's interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Director of Human Resources Claudia Rubio, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Aug 28, 2024 · control 08-AS-20220608142718

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Iby Strong, conducted an unannounced Case Management Visit. LPA met with Executive Director Justin Webber, and we discussed the purpose of the visit. Today's visit is in response to the self reported death of Resident 1 (R1 - see LIC811 Confidential Names List). R1 passed away on 8/3/2024. LPA conducted a wellness check at the facility, and no health or safety issues were identified. Residents observed appeared appropriate for the facility. Additional facility records were obtained on this date regarding R1's death. No deficiencies were cited or observed on this date. An exit interview was conducted. The Licensee was provided a copy of their appeal rights (LIC9058 03/22), along with a copy of this report.the state’s words, verbatim · CDSS document, Aug 12, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection. LPA Rodgers were granted entry into the facility by Executive Director Justin Weber. after identifying herself and stating the purpose of the inspection. The facility serves 511 elderly residents, age 60 and above, all whom may be non-ambulatory of which 370 may be bedridden. The facility is approved for delayed egress. LPA was accompanied by Executive Director Weber for a tour of the facility which was conducted inside and out and included a sample of resident units, the dining area and recreation rooms. Exterior and interior passageways were free from obstructions. Pull cords, sensor alerts and pendants are present in the facility. Resident and facility room temperatures were within a comfortable range. Each resident had clean and sufficient bed linens, towels, and washcloths. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars. Hot water temperature in residents’ bathrooms were compliant. [Continued on 809-C] [Continued from 809] Facility has a two-day supply of perishable and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. Food menus and activities schedule were posted. Facility chemicals and cleaning supplies were stored in a locked closet. The medication carts were locked and stored in the medication rooms. Medications were labeled and kept in compliance with label instructions. LPA interview confirmed the licensee provides assistance in meeting medical and dental needs. LPA interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained all required documents. LPA also conducted a review of In-service training procedures. There is designated gym area, large activity rooms throughout facility as well as gathering areas throughout the facility. At the time of visit, LPA observed two different large group activities in which many residents were participating. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. No deficiencies were sited at the time of visit. A final exit interview and a copy of this report, Licensee/Appeal Rights - LIC 9058 (rev. 01/16), were provided to , Executive Director Weber whose signature on this form acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Feb 21, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Iby Strong, conducted an unannounced Case Management Visit. LPA met with Director of Human Resources Claudia Rubio, and we discussed the purpose of the visit. Executive Director Justin Webber arrived shortly after. Today's visit is in response to the self reported death of Resident 1 (R1 - see LIC811 Confidential Names List). R1 passed away on 11/27/2023. LPA conducted a wellness check at the facility, and no health or safety issues were identified. Residents observed appeared appropriate for the facility. Additional facility records were obtained on this date regarding R1's death. No deficiencies were cited or observed on this date. An exit interview was conducted. The Licensee was provided a copy of their appeal rights (LIC9056 03/22), along with a copy of this report.the state’s words, verbatim · CDSS document, Dec 6, 2023