Inspection visit
Inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, observation, resident interview, and staff interview, the facility failed to provide a
clean and homelike environment. This affected one resident (#11) of six residents reviewed for
environment. The facility census was 89.
Findings include:
Review of the medical record revealed Resident #11 was admitted to the facility on [DATE]. Diagnoses
included type II diabetes mellitus, heart failure, depression, panic disorder, insomnia, history of falling,
restless leg syndrome, and migraine.
Review of the Minimum Data Set annual assessment dated [DATE], revealed Resident #11 was cognitively
intact. The resident required supervision or touching assistance for transfers and for walking ten feet once
standing.
Review of Resident #11's medical record revealed no documented information regarding the resident's bed
linens.
Interview on 02/24/25 at 3:41 P.M. with Resident #11 revealed staff never washed the resident's sheets.
Resident #11 reported it had probably been approximately one month since the last time her sheets were
changed. Resident #11 reported the top-left corner of the fitted sheet on her bed had been coming off of
the corner for awhile and she was unable to put it back on her own. Resident #11 reported having her own
sheets due to having a unique bed and that there were extra sheets staff could use.
Observation on 02/24/25 at 3:41 P.M. revealed Resident #11's bed had a light purple fitted sheet which was
completely off of the top left corner of the bed. There were numerous brownish-red smears covering the
side of the sheet which was facing the doorway. There was also a pillowcase hanging off of the siderail
attached to the resident's bed, which had numerous brownish-red smears all over it. The resident reported
the smears were all dried blood stains due to her picking at her skin.
Observations on 02/25/25 at 3:25 P.M. and on 02/26/25 at 9:25 A.M. revealed Resident #11 was resting in
bed. The resident's sheets were in the same condition, including the top-left corner coming off of the
mattress and the smears located on the fitted sheet and pillowcase. The condition of the sheets was visible
from the hallway.
Interview on 02/26/25 at 9:34 A.M. with Certified Nursing Assistant (CNA) #940 revealed there was
(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 4
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
02/27/2025
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)
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
no set schedule for resident bed linens to be changed. CNA #940 verified bed linens should be changed
whenever they were visibly dirty or soiled. CNA #940 was unsure of whether Resident #11 had their own
sheets.
Observation on 02/26/25 at 9:41 A.M. with CNA #940 verified the condition of Resident #11's sheets. CNA
#940 asked Resident #11 if CNA #940 could change Resident #11's sheets and the resident responded
yes, they have been dirty for awhile.
Event ID:
Facility ID:
365162
If continuation sheet
Page 2 of 4
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
02/27/2025
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)
F 0791
Provide or obtain dental services for each resident.
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, observation, resident interview, staff interview, and review of facility policy, the facility
failed to assist residents in obtaining routine dental care. This affected one resident (#68) of two residents
reviewed for dental care. The facility census was 89.
Residents Affected - Few
Findings include:
Review of the medical record revealed Resident #68 was admitted to the facility on [DATE]. Diagnoses
included type II diabetes mellitus, depression, anxiety, hypertension, and peripheral vascular disease.
Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #68 was
cognitively intact. The resident did not have any broken teeth or dentures.
Review of the current physician orders for February 2025 identified an order dated 06/12/23 for may consult
dental as needed.
Review of Resident #68's medical record revealed no evidence the resident was ever offered or received
routine dental services while residing in the facility.
Interview on 02/24/25 at 9:39 A.M. revealed Resident #11 stated they needed dentures because their teeth
were rotting. Resident #11 reported no one at the facility had inquired about dental services and the
resident had not seen a dentist since residing in the facility.
Observation on 02/24/25 at 9:39 A.M. revealed Resident #11 had visibly darkened areas on several of their
teeth.
Interview on 02/26/25 at 11:30 A.M. with the Regional Director of Clinical Services #721 revealed there was
a dentist who came into the facility on a quarterly basis. The Regional Director of Clinical Services #721
reported residents were screened for whether they would like dental services upon admission to the facility.
A follow-up interview on 02/27/25 at 11:30 A.M. with the Regional Director of Clinical Services #721
revealed the facility could not find Resident #68's admission documents to confirm whether or not the
resident was offered dental services. The Regional Director of Clinical Services #721 verified there was no
evidence Resident #68 was ever offered or received routine dental services while residing in the facility.
Review of the facility policy titled Dental Services, revised December 2016, revealed routine and
emergency dental services were available to meet the resident's oral health services in accordance with the
resident's assessment and plan of care. The policy also stated all dental services provided would be
recorded in the resident's medical record.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365162
If continuation sheet
Page 3 of 4
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
02/27/2025
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)
F 0825
Provide or get specialized rehabilitative services as required for a resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, observation, resident interview, and staff interview, the facility failed to ensure Resident #68
timely received an evaluation by therapy services for a motorized wheelchair. This affected one (Resident
#68) of five residents reviewed for rehabilitation services. The facility census was 89.
Residents Affected - Few
Findings include:
Review of the medical record revealed Resident #68 was admitted to the facility on [DATE]. Diagnoses
included type II diabetes mellitus, depression, anxiety, hypertension, and peripheral vascular disease.
Review of the Minimum Data Set quarterly assessment dated [DATE] revealed Resident #68 was
cognitively intact. The resident was dependent on assistance from staff for activities of daily living.
Review of Resident #68's general progress notes dated 08/07/24 and timed 5:51 P.M. revealed a nurse
practitioner was in to see the resident. The resident requested to get a motorized wheelchair with a new
order for a therapy consultation for a motorized wheelchair evaluation.
Review of Resident #68's general progress notes dated 12/09/24 and timed 3:03 P.M. revealed a nurse
practitioner was in the facility making rounds with a new order for a therapy evaluation for a motorized
wheelchair.
Review of the current physician orders for February 2025 identified an order dated 12/09/24 for consultation
with therapy for a motorized wheelchair evaluation.
Review of Resident #68's medical record revealed no evidence the resident was ever evaluated by therapy
for a motorized wheelchair.
Interview on 02/24/25 at 9:30 A.M. revealed Resident #11 stated they had requested a motorized
wheelchair multiple times but had never been evaluated for or received one.
Observation on 02/24/25 at 9:30 A.M. revealed there was no wheelchair in Resident #11's room.
Interview on 02/26/25 at 8:34 A.M. with the Director of Therapy Services #742 verified Resident #11 had an
order dated 12/09/24 for therapy to evaluate the resident for a motorized wheelchair and the resident had
never been evaluated for one.
Interview on 02/27/25 at 11:30 A.M. with the Regional Director of Clinical Services #721 verified Resident
#68 had expressed interest in a motorized wheelchair on 08/07/24 and on 12/09/24 with a new order to be
evaluated by therapy. The Regional Director of Clinical Services #721 verified there was no evidence or
documentation the resident had ever been evaluated by therapy for a motorized wheelchair.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365162
If continuation sheet
Page 4 of 4
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Back to topCitations
4 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F825 - Specialized rehabilitative services
Provide or get specialized rehabilitative services as required for a resident.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
F791 - Dental Services
Provide or obtain dental services for each resident.
F584 - Safe Environment
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.
FAQ · About this visit
Common questions about this visit
What happened during the February 27, 2025 survey of WESLEYAN VILLAGE?
This was a inspection survey of WESLEYAN VILLAGE on February 27, 2025. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at WESLEYAN VILLAGE on February 27, 2025?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide or get specialized rehabilitative services as required for a resident."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.