Inspection·August 26, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of shower schedules, and staff interview, the facility failed to ensure residents were provided adequate bathing as scheduled. This affected three (#212, #277, and #300) of three residents reviewed for activities of daily living. The facility census was 82. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #212 revealed an admission date of 03/14/24. Diagnoses include generalized weakness, hypertension, Alzheimer's dementia, depression, and elevated cholesterol. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #212 was assessed as severely cognitively impaired and required substantial/maximal assistance with showering and bathing as well as hygiene. Review of facility shower schedule revealed Resident #212 was scheduled for showers/baths every Monday and Friday on day shift. Review of the facility shower schedule for 06/01/24 through 08/26/24 revealed Resident #212 was scheduled to receive 25 showers/baths. Review of facility shower documentation revealed Resident #212 received showers/baths on 06/06/24, 06/17/24, 07/01/24, 07/05/24, 07/10/24, 07/15/24, 08/09/24, and 08/17/24. Further review of Resident #212's medical record revealed the resident was in the hospital on [DATE]. 2. Review of the medical record for Resident #277 revealed an admission date of 05/15/23. Diagnoses include seizures, asthma, generalized muscle weakness, abnormalities of gait and mobility, need for assistance with personal care, major depressive disorder, anxiety disorder,and hypertension. Review of the annual MDS assessment dated [DATE] revealed Resident #277 was assessed as cognitively intact and required substantial/maximal assistance with showers/baths as well as hygiene. Review of the facility shower schedule revealed Resident #277 was scheduled for showers/baths every Monday and Thursday in the evening. Review of the facility shower schedule for 06/01/24 through 08/26/24 revealed Resident #277 was scheduled to receive 25 showers/baths. Review of facility shower documentation revealed Resident #277 received showers/baths on 06/06/24, 06/20/24, 06/21/24, 06/27/24, 07/18/24, 07/25/24, 07/29/24, 08/01/24, 08/05/24, 08/12/24, 08/15/24, (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 365162 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesleyan Village 807 West Ave Elyria, OH 44035 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)