Wesley Manor

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF812Feb 25, 2022

  Based on observation, interview, record review and facility policy review, it was determined the facility failed to maintain professional standards in two (2) of two (2) kitchens. Specifically, the facility failed to remove five (5) dented canned food items from one (1) of two (2) kitchens and failed to maintain accurate and complete refrigerator temperature logs in two (2) of two (2) kitchens. These failures had the potential to affect all residents of the facility who received food from the two kitchens. The findings include: Review of facility policy DRY STORAGE, revised 01/2019, revealed damaged dry goods containers were stored together in the main storeroom in a separate and distinct area away from the other food items. […]

• No harm, potential for more than minimal, patternF880Feb 25, 2022

  Based on observation, interview, and facility policy review, it was determined the facility failed to maintain an infection control program to provide a safe and sanitary environment to prevent infections. Observations revealed Registered Nurse (RN) #1 wore an inappropriate face covering and popped pills into his bare hands before placing the medication in a medicine cup while administering medications. Additionally, observations revealed bio-hazard containers placed in improper locations to facilitate proper disposal of used personal protective equipment (PPE). The findings include: 1. […]

• No harm, potential for more than minimal, isolatedF565Jul 25, 2025

  Based on interview, record review, and facility policy review, the facility failed to ensure resident council grievances were acted upon for two (Resident (R) 51 and R57) of six residents who attended resident council meetings. Additionally, six of six residents chosen by the facility to participate in a resident group interview did not know how to file a grievance or who the facility designated as the staff person responsible for assisting and responding to grievances that resulted from resident council meetings.The findings included: A facility policy titled, Grievance Process, revised 05/2021, revealed the Policy, stated it was, To ensure each resident can address dissatisfaction with policies, procedures, staff, and/or other residents and seek resolution without reprisal. […]

• No harm, potential for more than minimal, isolatedF684Jul 25, 2025

  Based on observation, interview, record review, and facility policy review, the facility failed to follow physician's orders for one (Resident (R) 3) of 16 sampled residents. Staff failed to follow R3's physician's orders for both the treatment of a skin tear to the resident's right arm, as well as a surgical wound to the left heel.The findings included:Review of a facility policy titled, Skin Breakdown/Pressure Ulcer, revised 01/2025, revealed, 2. All interventions are reviewed with the resident's physician for approval. The policy revealed, 4. If breakdown has been identified: i. The Team Manager to obtain orders from the resident's physician and iv. […]

• No harm, potential for more than minimal, isolatedF880Jul 25, 2025

  Based on observation, interview, record review, and Centers for Disease Control and Prevention (CDC) information, the facility failed to ensure staff donned gloves when administering eye drops to one (R63) of six residents reviewed for medication administration. In addition, the facility failed to ensure staff performed hand hygiene as indicated during wound care for one (Resident (R) 3) of five residents reviewed for infection control.The findings included:1. Review of a CDC publication titled, Clinical Safety: Hand Hygiene for Healthcare Workers, dated 02/27/2024, revealed gloves should be worn, When needed for Standard Precautions (when you anticipate that you will come in contact with blood or other infectious materials, mucous membranes, non-intact skin, potentially contaminated skin,… […]