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 |
