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Deficiency Records for Wesley Village
A list of the most recent deficiencies for Wesley 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 Wesley 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-07-19 | 2024-09-17 | N |
| 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 | 2024-07-19 | 2024-09-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-07-19 | 2024-09-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-07-19 | 2024-09-17 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-07-19 | 2024-09-17 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-07-19 | 2024-09-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-07-19 | 2024-09-17 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-07-19 | 2024-09-17 | 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 | 2024-07-19 | 2024-09-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-07-19 | 2024-09-17 | 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 | 2024-07-30 | 2024-08-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-07-30 | 2024-08-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-14 | 2024-05-27 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-06-30 | 2023-08-22 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-06-30 | 2023-08-22 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-06-30 | 2023-08-22 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-06-30 | 2023-08-22 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-06-06 | 2023-07-17 | 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 | 2023-06-06 | 2023-07-17 | 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 | 2023-01-17 | 2023-02-28 | Y |
| Provide or obtain dental services for each resident. | Health | 2023-01-17 | 2023-02-28 | Y |
| Assess the resident when there is a significant change in condition | Health | 2022-07-29 | 2022-09-16 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-07-29 | 2022-09-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-07-29 | 2022-09-16 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-07-29 | 2022-09-16 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-07-29 | 2022-09-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-29 | 2022-09-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-29 | 2022-09-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-07-29 | 2022-09-16 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-07-29 | 2022-09-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-29 | 2022-09-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-07-19 | 2022-08-24 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-07-19 | 2022-08-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-07-19 | 2022-08-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-19 | 2022-08-24 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-07-19 | 2022-08-24 | N |
| 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 | 2022-05-26 | 2022-06-27 | Y |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2022-02-15 | 2022-03-15 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-02-15 | 2022-03-15 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-22 | Not Fixed | Y |
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