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? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2023-09-15 | 2023-10-05 | Y |
| 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 | 2023-03-09 | 2023-03-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-03-07 | 2023-03-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-03-07 | 2023-03-14 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-03-07 | 2023-03-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-07 | 2023-03-14 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-09-01 | 2022-09-19 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2022-09-01 | 2022-09-19 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-06-01 | 2022-06-17 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-06-01 | 2022-06-17 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-06-01 | 2022-06-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-06-01 | 2022-06-16 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2022-06-01 | 2022-06-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-26 | 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 | 2021-04-15 | 2021-04-29 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-04-15 | 2021-04-20 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-04-15 | 2021-04-20 | N |
