Wesley Manor Health Center

In the surveyor’s words

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

• Actual harm, isolatedF690Dec 11, 2025

  Based on interview and record review, the facility failed to ensure a foley catheter placement was documented and follow-up assessments were completed after a change in urine characteristics were observed for 1 of 3 residents reviewed for catheters. (Resident B) This deficient practice resulted in Resident B being admitted to the hospital with urethral trauma.Findings include:During an interview, on 12/11/25 at 3:04 p.m., Resident B's family indicated the physician in the emergency room had indicated Resident B's catheter was inserted at the facility incorrectly. She was told a nursing student placed the catheter; the balloon was in his urethra and damaged it.The clinical record for Resident B was completed on 12/11/25 at 10:32 a.m. […]

• Actual harm, isolatedF604Jun 18, 2024

  Based on observation, interview and record review, the facility failed to ensure a consent with the identified medical reason for the use of a restraint was completed at the initiation of the restraint, to establish a time frame for continuing the use of the restraint and to establish how the restraint would be decreased and discontinued for 1 of 1 resident reviewed for restraints. (Resident 70) This deficient practice resulted in Resident C having three (3) falls with major injuries while using the restraint, had 3 emergency room evaluations and was diagnosed with nasal fractures, lacerations to her face which required sutures, and a laceration to her upper lip which required sutures. […]

• Actual harm, isolatedF689Sep 28, 2023

  Based on observation, interview and record review, the facility failed to protect a resident from injury while walking with the resident from the bathroom to the resident's recliner without using a gait belt for 1 of 3 residents reviewed for accidents. (Resident B) Resident B fell and hit their head resulting in a laceration which was treated with staples and an interval development of a right frontoparietal convexity subdural hematoma (a blood vessel in the space between the skull and the brain was damaged). Finding includes: During an observation, on 9/28/23 at 9:41 a.m., Resident B was observed sitting in a recliner with her feet elevated. She appeared clean and dry and was wearing nonskid socks. […]

• No harm, potential for more than minimal, widespreadF812Apr 4, 2023

  Based on observation, interview, and record review, the facility failed to store food, and wash and dry dishes in a sanitary manner resulting in the potential for all residents who consume food from the kitchen to become ill from food borne illness. Findings include: During a kitchen tour, on 03/30/23 at 10:00 a.m., with the Director of Dining Services (DDS) the following was observed: 1. The clean and dry storage rack was observed to have: a) A small metal tong with a brown particle on the tong. […]

• No harm, potential for more than minimal, isolatedF554May 21, 2026

  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. […]