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Deficiency Records for Wesley Manor

A list of the most recent deficiencies for Wesley Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

A list of the most recent deficiencies for Wesley Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
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. Health 2022-09-16 2023-01-13 Y
Allow residents to self-administer drugs if determined clinically appropriate. Health 2022-02-25 2022-05-06 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-02-25 2022-05-06 N
Provide and implement an infection prevention and control program. Health 2022-02-25 2022-05-06 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2019-06-25 2019-09-02 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2019-06-25 2019-08-01 N
Have corridors or aisles that are unobstructed and are at least 8 feet in width. Fire Safety 2019-06-25 2019-08-01 N
Install a fire alarm system that can be heard throughout the facility. Fire Safety 2019-06-25 2019-08-01 N
Install corridor and hallway doors that block smoke. Fire Safety 2019-06-25 2019-08-01 N
Have simulated fire drills held at unexpected times. Fire Safety 2019-06-25 2019-08-01 N
Meet requirements for the use of electrical equipment. Fire Safety 2019-06-25 2019-08-01 N
Allow resident to participate in the development and implementation of his or her person-centered plan of care. Health 2018-05-02 2018-06-16 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2018-05-02 2018-06-16 N
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. Health 2018-05-02 2018-06-16 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2018-05-02 2018-06-16 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2018-05-02 2018-06-16 N

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