Inspection visit
Fire Safety inspection
Citations
19 citations recorded*CMS
This is a Fire Safety survey. CMS cites these findings under the Life Safety Code and Emergency Preparedness rules, a separate set from the health (F-tag) deficiencies. The codes and grading differ, so these do not link to the health violation pages.
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.
- 0761GeneralS&S Fpotential for harm
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0006GeneralS&S Bno actual harm
Conduct risk assessment and an All-Hazards approach.
- 0007GeneralS&S Bno actual harm
Address patient/client population and determine types of services needed.
- 0025GeneralS&S Bno actual harm
Create arrangements with other facilities to receive patients.
- 0032GeneralS&S Bno actual harm
Provide primary/alternate means for communication.
- 0034GeneralS&S Bno actual harm
Provide a means of sharing information on occupancy/needs.
- 0036GeneralS&S Bno actual harm
Establish emergency prep training and testing.
- 0037GeneralS&S Bno actual harm
Establish staff and initial training requirements.
- 0039GeneralS&S Cno actual harm
Conduct testing and exercise requirements.
- 0100GeneralS&S Cno actual harm
Meet other general requirements.
- 0211GeneralS&S Epotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0324GeneralS&S Epotential for harm
Provide properly protected cooking facilities.
- 0342GeneralS&S Epotential for harm
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
- 0355GeneralS&S Fpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0372GeneralS&S Epotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0914GeneralS&S Fpotential for harm
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- 0918GeneralS&S Fpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0923GeneralS&S Epotential for harm
Have proper medical gas storage and administration areas.
FAQ · About this visit
Common questions about this visit
What happened during the May 23, 2025 survey of WESLEY ENHANCED LIVING AT STAPELEY?
This was a inspection survey of WESLEY ENHANCED LIVING AT STAPELEY on May 23, 2025. The surveyor cited 19 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at WESLEY ENHANCED LIVING AT STAPELEY on May 23, 2025?
Yes, 19 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "To conduct inspection, testing and maintenance of fire doors by qualified individuals."
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
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.