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Deficiency Records for Wesleyan Village
A list of the most recent deficiencies for Wesleyan Village. 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 Wesleyan Village. 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? |
|---|---|---|---|---|
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-08-26 | 2024-09-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-26 | 2024-09-05 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-06-12 | 2024-07-30 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-06-27 | 2024-07-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-06-27 | 2024-07-17 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-06-27 | 2024-07-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-06-27 | 2024-07-17 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-06-27 | 2024-07-17 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-06-27 | 2024-07-17 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2024-06-27 | 2024-07-17 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-06-27 | 2024-07-17 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2024-06-27 | 2024-07-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-04-16 | 2024-04-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-04-16 | 2024-04-24 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-04-16 | 2024-04-24 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-04-16 | 2024-04-24 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2024-03-04 | 2024-03-18 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-20 | 2024-01-08 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-12-20 | 2024-01-08 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-12-20 | 2024-01-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-03 | 2024-01-08 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-03 | 2024-01-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-07 | 2023-03-10 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-05-16 | 2022-07-22 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-05-10 | 2022-07-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-05-10 | 2022-07-21 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-05-10 | 2022-07-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-10 | 2022-07-21 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-05-10 | 2022-07-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-05-10 | 2022-07-21 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-05-16 | 2022-07-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-16 | 2022-07-20 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-05-16 | 2022-07-20 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-05-16 | 2022-07-20 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2022-05-16 | 2022-07-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-16 | 2022-07-20 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-05-16 | 2022-07-20 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-16 | 2022-07-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-16 | 2022-07-20 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-05-16 | 2022-07-20 | Y |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2022-05-16 | 2022-06-17 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-12-01 | 2021-12-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-19 | 2021-11-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-10-19 | 2021-11-16 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-05-09 | 2019-06-14 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2019-05-09 | 2019-06-14 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-05-09 | 2019-06-14 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-05-09 | 2019-06-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-05-09 | 2019-06-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-05-09 | 2019-06-14 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2019-05-09 | 2019-06-14 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-05-09 | 2019-06-14 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-05-09 | 2019-06-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-05-09 | 2019-06-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-09 | 2019-06-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-09 | 2019-06-14 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-05-09 | 2019-06-14 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2019-05-09 | 2019-06-14 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-05-09 | 2019-06-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-05-09 | 2019-06-14 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2019-05-09 | 2019-06-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-05-09 | 2019-06-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-09 | 2019-06-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-05-09 | 2019-06-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-05-09 | 2019-06-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-05-09 | 2019-06-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-04-05 | 2018-05-20 | 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 | 2018-04-05 | 2018-05-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-04-05 | 2018-05-20 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2018-04-05 | 2018-05-20 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2018-04-05 | 2018-05-20 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-04-05 | 2018-05-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-04-05 | 2018-05-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-04-05 | 2018-05-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-04-05 | 2018-05-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-04-05 | 2018-05-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-04-05 | 2018-05-20 | N |
| Ensure that gas fire places are out of the reach of patients and can be shut off if unit is working improperly. | Fire Safety | 2018-04-05 | 2018-05-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-04-05 | 2018-05-20 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2018-04-05 | 2018-05-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-04-05 | 2018-05-20 | N |
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