Wesley Village

In the surveyor’s words

From the most serious findings on record at Wesley Village, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 16, 2024

  Based on observations, a review of clinical records, select facility policy, resident incident/accident report and staff interviews, it was determined that the facility failed to provide adequate staff supervision and effective safety measures to prevent elopement for two residents (Resident CR1 and Resident 2) out of 4 residents reviewed, The facility further failed to identify staff's reliance on the facility's alarm system to prevent elopements and the deficiencies of this system to prevent future unsupervised exits from the facility, which placed residents in immediate jeopardy of future unsupervised exits from the facility and the potential for serious bodily injury or death. […]

• Actual harm, isolatedF689May 13, 2021

  Based on review of clinical records and select resident incident/accident reports, observation and staff interview, it was determined the facility failed to provide necessary staff supervision and implement effective person-centered safety measures based on individual resident needs to promote resident safety and prevent falls, which resulted in serious injury, head injuries and fracture, to one resident out of three sampled (Resident 1). Findings include: A review of the clinical record revealed that Resident 1 was readmitted to the facility on [DATE], with diagnoses which included, unspecified dementia with behavioral disturbance, unspecified abnormality of gait, and unspecified mental disorder. […]

• No harm, potential for more than minimal, widespreadF886Feb 15, 2022

  Based on a review of the facility's COVID-19 testing records and standards established by the Centers for Medicare & Medicaid Services and staff interview, it was determined that the facility failed to develop and implement a functional system to maintain accurate documentation of testing completed and the results of each staff test during an outbreak including for one employee out of three sampled (Employee 2). Findings include: According to the Centers for Medicare and Medicaid Services, Center for Clinical Standards and Quality/Survey & Certification Group QSO-Memo - 20-38-NH initially dated August 26, 2020 and revised September 10, 2021, when newly identified COVID-19 positive staff or resident in a facility that is unable to identify close contacts, the facility is to test all staff… […]

• No harm, potential for more than minimal, patternF812Feb 13, 2026

  Based on observation and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of foodborne illness in the food and nutrition services department.Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. […]

• No harm, potential for more than minimal, patternF684May 9, 2025

  Based on clinical record review, review of select facility policy, and staff interview, it was determined the facility failed to provide quality care as evidenced by the facility failure to ensure physician orders were followed for the administration of medication for one resident (Resident 61) and further failed to develop procedures and criteria for a palliative care program (Specialized medical care for people with serious illness. This type of care is focused on providing relief from the symptoms and stress of a serious illness. […]