Wesley Manor Health Center

Based on observation, interview and record review, the facility failed to ensure an Interdisciplinary Team (IDT) assessment, physician's order, and care plan related to the self-administration of medications was obtained prior to the self-administration of medications for 1 of 1 resident reviewed for self-medication administration. (Resident 7)Findings include: During an observation, on 5/14/26 at 10:30 a.m., Resident 7 was observed resting in bed with her eyes closed. A cup, containing six (6) pills, was observed on the bedside table. There were no staff present in the room at the time of the observation. The clinical record for Resident 7 was reviewed on 5/18/26 at 8:59 a.m. The diagnoses included, but were not limited to, chronic respiratory failure with hypoxia, emphysema, and hypertension. The clinical record did not contain an IDT assessment, physician's order, or a care plan related to the self-administration of medications. During an interview, on 5/14/26 at 10:35 a.m., LPN 2 indicated there were six pills left at the bedside and she was not aware if Resident 7 was able to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure a physician's order for the administration of oxygen was followed for 1 of 2 residents reviewed for respiratory care. (Resident 7)Findings include:During an observation, on 5/14/26 at 10:30 a.m., Resident 7 was receiving oxygen via nasal cannula at 3.5 liters per minute (lpm). Resident 7 was observed resting in bed with her eyes closed.During an observation, on 5/18/26 at 9:31 a.m., Resident 7 was receiving oxygen via nasal cannula at 3.5 lpm. Resident 7 was observed resting in bed.During an observation, on 5/18/26 at 12:27 p.m., Resident 7 was receiving oxygen via nasal cannula at 3.5 lpm. Resident 7 was observed resting in bed.The clinical record for Resident 7 was reviewed on 5/18/26 at 8:59 a.m. The diagnoses included, but were not limited to, respiratory failure with hypoxia, emphysema, and hypertension.A care plan, initiated on 6/30/25, indicated Resident 7 had emphysema and chronic obstructive pulmonary disease and oxygen settings were to be according to the physician's order.A care plan,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure there was documentation the bed hold policy was provided to a resident for 1 of 3 residents reviewed for discharge. (Resident 81) The deficient practice was corrected on 5/21/25, prior to the start of the survey, and was therefore past noncompliance. Findings include: The clinical record for Resident 81 was reviewed on 5/28/25 at 2:42 p.m. The diagnoses included, but were not limited to, weakness, Crohn's disease, and dementia. The electronic health record indicated Resident 81 was discharged from the facility to the hospital on 4/8/25. There was no documentation to indicate the bed hold policy had been given to the resident or the resident's representative at the time of the discharge. There was no documentation to indicate the bed hold policy had been emailed or sent by postal service to the resident's representative if needed. During an interview, on 6/2/25 at 11:47 a.m., the Executive Director indicated in May of 2025, the facility started emailing copies of the bed hold policy to the resident's representative…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure the physician's orders for peritoneal dialysis were followed for 1 of 1 resident reviewed for dialysis. (Resident 50) Findings include: The clinical record for Resident 50 was reviewed on 5/29/25 at 10:17 a.m. The diagnoses included, but were not limited to, congestive heart failure, kidney failure, kidney disease, chronic obstructive pulmonary disease, type 2 diabetes mellitus, end stage renal disease, and dependence on renal dialysis. A physician's order, dated 12/10/24, indicated to take the resident's vital signs before and after dialysis and to use the morning weight and the systolic blood pressure to determine the dose for dialysis. A physician's order, dated 12/10/24, indicated the resident needed weighed every morning and when the resident's weight was greater than 216 pounds to call the dialysis clinic for further instructions. If the systolic blood pressure was less than 110, use one green (2.5% dextrose) and one yellow (1.5% dextrose) bag regardless of the weight. If the systolic blood pressure was less…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure a thorough investigation was completed to include staff interviews after an injury of unknown source was identifed for 1 of 5 residents reviewed for accidents. (Resident 34) Finding includes: The clinical record for Resident 34 was reviewed on 6/14/24 at 11:12 a.m. The diagnoses included, but were not limited to Alzheimer's disease, dementia, unspecified intellectual disability, cognitive communication deficit, and other reduced mobility. A facility incident report indicated, on 4/7/24, there was bruising noted to Resident 34's right knee with swelling. The on-call nurse practitioner (NP) gave orders to do an x-ray as a precaution. X-ray results showed an acute fracture to the right hip and the bone was diffusely demineralized. A facility incident report with a follow-up added on 4/10/24, indicated on 4/6/24 at 10:00 a.m., the resident was observed to have swelling and her right leg appeared to be turned to the right. On 4/7/24, x-ray results came back and showed an acute right hip fracture. On 4/10/24, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to cue and assist a resident during lunch according to the plan of care and to assess/reweigh a resident for a significant weight change for 1 of 4 residents reviewed for nutrition. (Resident 45) Finding includes: During an observation, on 6/12/24 at 12:13 p.m., Resident 45 was sitting up in a pedal Broda (chair for positioning) at the dining table with his eyes closed. His plate still had most of his food. The staff were not cueing or assisting him to eat. Most of the other residents in the dining room had already finished eating. During an observation, on 6/12/24 at 12:24 p.m., a female staff asked Resident 45 if he was hungry, and the resident shook his head for no. The resident was very thin. During an observation, on 6/13/24 at 12:05 p.m., Resident 45 was sitting in his pedal Broda at the dining table. The resident was not eating on his own and the staff were not encouraging or assisting the resident to eat. The staff were helping other residents to eat their lunch. During on observation on 6/14/24 at 12:07…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to provide documentation to show the resident specific psychosis/behaviors which were used as the rationale for declining a gradual dose reduction (GDR) of an antipsychotic for 1 of 5 residents reviewed for unnecessary medications. (Resident 38) Finding includes: The clinical record for Resident 38 was reviewed on 6/14/24 at 10:40 a.m. The diagnoses included, but were not limited to, unspecified dementia with psychotic disturbance, psychotic disorder with delusions due to a known physiological condition, severe major depressive disorder without psychotic features, and dementia with anxiety. A physician's order, dated 9/22/23, indicated to give risperidone (an antipsychotic) 0.25 milligrams (mg) three tablets one time a day for the psychotic disorder with delusions. A pharmacy GDR request, dated 3/1/24, indicated the resident received risperidone 0.75 mg daily and to please attempt a GDR of the risperidone to 0.5 mg daily. The physician response indicated the GDR was declined. The clinical rationale included the resident had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure employee meals were not stored in the nutrition refrigerator, failed to ensure items were dated with open dates and labeled with a name, and failed to ensure thermometers were in the refrigerator/freezers for 3 of 10 nutritional and unit refrigerators observed for safe and sanitary conditions. Findings include: 1. During an observation, on 6/13/24 at 8:23 a.m., the First Floor Unit nutrition refrigerator, located in the medication room, was found to contain a lunch bag. At that time, LPN 1 indicated it was her lunch in the bag. Also found in the refrigerator was a 16-ounce open bottle of strawberry poppy seed salad dressing. The bottle had been opened and was found without an open date or a label indicating who was the owner of the salad dressing. A sign found on the front of the refrigerator indicated .This fridge is for ensures, pudding, applesauce's only. All Staff and resident food/drink items to be put in the fridges at either end of the hallway per state guidance During an interview, on 6/13/24 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.