Inspection Report Summary
The most recent inspection on April 28, 2025, identified multiple deficiencies related to resident privacy, use of restraints, activities of daily living, medication management, food safety, and infection control. Earlier inspections showed a pattern of issues including failure to provide proper post-fall care, protection from abuse and involuntary seclusion, incomplete care plans, and food safety concerns. Complaint investigations substantiated verbal abuse and involuntary seclusion by a staff member and found lapses in neurological monitoring and infection control. Enforcement actions such as staff suspension and agency notification were reported, but fines or license actions were not listed in the available reports. The inspection history indicates ongoing challenges with resident care and safety, with no clear improvement trend over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
23% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 8
Date: Apr 28, 2025
Visit Reason
The inspection was conducted to evaluate compliance with resident rights, accommodations, use of restraints, activities of daily living, range of motion care, medication storage and labeling, food safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' privacy and dignity by staff not knocking before entering rooms, failure to accommodate resident needs such as call light placement and appropriate dining seating, improper use of physical restraints, inadequate provision of activities of daily living including grooming and showering, lack of interventions for residents with contractures, improper medication labeling and storage, food safety violations including unlabeled and open food items and improper use of hair and beard restraints in the kitchen, and failure to maintain infection control practices including hand hygiene and equipment sanitization.
Deficiencies (8)
Facility failed to ensure staff knocked on residents' doors before entering, violating residents' rights to privacy and dignity.
Facility failed to ensure call lights were within reach and dining tables were appropriate height for wheelchairs for certain residents.
Facility failed to ensure residents were free from physical restraints unless medically necessary, including improper use of bed rails.
Facility failed to provide necessary assistance with activities of daily living including grooming and showering as scheduled.
Facility failed to provide appropriate care to maintain or improve range of motion for a resident with contractures.
Facility failed to ensure drugs were labeled properly, medication carts were locked when unattended, and controlled medications were secured with two locks.
Facility failed to store, prepare, distribute, and serve food in accordance with professional standards, including failure to label and date food, dispose of open or damaged food, and proper use of hair and beard restraints in the kitchen.
Facility failed to establish and maintain an infection prevention and control program, including failure of volunteer to perform hand hygiene during dining services, failure to disinfect blood pressure cuffs between residents, and improper infection control during peri care.
Report Facts
Residents reviewed for rights: 10
Residents reviewed for accommodations: 8
Residents reviewed for restraints: 5
Residents reviewed for activities of daily living: 12
Residents reviewed for range of motion: 8
Medication carts reviewed: 6
Residents affected by medication cart deficiencies: 4
Residents affected by infection control deficiencies: 4
Volunteers observed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Named in privacy violation for not knocking on residents' doors |
| CNA B | Certified Nursing Assistant | Named in privacy violation for not knocking on residents' doors |
| DON | Director of Nursing | Interviewed regarding privacy, call light policy, restraints, ADL care, medication storage, infection control |
| ADM | Administrator | Interviewed regarding privacy, call light policy, restraints, ADL care, medication storage, food safety, infection control |
| MA E | Medication Aide | Named in infection control deficiency for not sanitizing blood pressure cuff |
| MA F | Medication Aide | Named in infection control deficiency for not sanitizing blood pressure cuff |
| CNA K | Certified Nursing Assistant | Named in infection control deficiency for improper peri care technique |
| Dishwasher H | Dishwasher | Named in food safety deficiency for improper beard restraint use |
| General Manager | General Manager | Named in food safety deficiency for improper beard restraint use and food labeling |
| Kitchen Manager | Kitchen Manager | Named in food safety deficiency for food labeling and dating |
| Dietician | Dietician | Named in food safety deficiency for food labeling and dating |
| RN J | Registered Nurse | Named in infection control deficiency for peri care and medication cart security |
| LVN D | Licensed Vocational Nurse | Named in infection control deficiency for medication cart security and peri care |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 12, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide appropriate treatment and care according to orders, resident preferences, and goals, specifically related to Resident #1's fall and subsequent care.
Complaint Details
The complaint investigation focused on Resident #1's fall on 03/12/25, failure to perform neurological assessments post-fall, and inadequate monitoring leading to hospitalization. The investigation included multiple staff interviews, family statements, and review of medical records confirming the facility's failure to follow standard care protocols. The complaint also included concerns about improper storage of oxygen equipment for Resident #2.
Findings
The facility failed to ensure Resident #1 received proper neurological assessments and monitoring after a fall on 03/12/25, despite documented injuries including fractures and lacerations. Staff did not perform required neurological checks post-fall, and Resident #1 was sent back to the hospital due to deteriorating condition. Additionally, the facility failed to properly store Resident #2's nebulizer mask, posing infection risk.
Deficiencies (2)
Failure to provide appropriate treatment and care according to orders and resident preferences, specifically failure to conduct neurological assessments and monitoring after Resident #1's fall.
Failure to ensure Resident #2's nebulizer mask was stored away when not in use, risking infection.
Report Facts
Number of falls for Resident #1 during admission: 2
Blood pressure readings for Resident #1 on 03/12/25: Multiple readings including 128/64, 115/65, 136/64, 117/65 mmHg at various times.
Pain level assessments for Resident #1 on 03/12/25: Pain scores ranged from 0/10 to 3/10 at various times.
Oxygen saturation levels for Resident #1 on 03/12/25: O2 saturation values ranged from 92% to 96% at various times.
Frequency of neurological assessments required post-fall: Every 15 minutes four times, every two hours four times, and every shift for 72 hours.
Dates medication Clopidogrel Bisulfate held: Held from 03/12/25 through 03/16/25.
Date of fall incident: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Responsible for initial assessment post-fall, failed to initiate neurological assessments on Resident #1. |
| RN D | Registered Nurse | Provided care post-fall, did not notify LVN B of need for neurological assessments. |
| LVN B | Licensed Vocational Nurse | Observed Resident #1 with low blood pressure, notified EMS, unaware neurological assessments were not performed. |
| CNA C | Certified Nursing Assistant | Witnessed Resident #1 fall, notified LVN A, did not observe neurological assessments performed. |
| NP | Nurse Practitioner | Reviewed hospital records, expected neurological assessments every shift post-fall. |
| DON | Director of Nursing | Oversaw nursing staff, responsible for ensuring neurological assessments were performed and documented. |
| MD | Medical Doctor | Provided medical oversight, aware of fall and hospitalizations, emphasized importance of monitoring post-fall. |
| LVN F | Licensed Vocational Nurse | Notified DON of Resident #1's transfer back to hospital due to low blood pressure. |
| CNA G | Certified Nursing Assistant | Instructed to monitor Resident #1 post-fall, did not observe neurological assessments performed. |
| ADM | Administrator | Oversaw facility operations, expected proper oxygen equipment storage and staff notifications. |
| LVN A | Licensed Vocational Nurse | Administered nebulizer treatments to Resident #2, failed to store nebulizer mask properly. |
| LVN B | Licensed Vocational Nurse | Responsible for rinsing, drying, and bagging nebulizers, aware of importance of proper oxygen equipment storage. |
| Infection Preventionist | Stated nurses responsible for cleaning and storing nebulizer masks, emphasized infection control importance. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 3, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding allegations of verbal abuse and involuntary seclusion of Resident #1 by an agency CNA on 02/03/25.
Complaint Details
The complaint investigation was substantiated based on video surveillance, staff and resident interviews, and facility records. CNA A was found to have verbally abused Resident #1 and subjected her to involuntary seclusion. The agency CNA was suspended and prohibited from returning to the facility. The facility reported the abuse to the staffing agency and local police. Resident #1 was fearful and transferred to another facility.
Findings
The facility failed to protect Resident #1 from verbal abuse and involuntary seclusion by CNA A on 02/03/25. Video evidence showed CNA A verbally abusing the resident and forcibly pushing her into her room, holding the door closed while the resident was heard yelling to be let out. The facility took corrective actions including prohibiting CNA A from returning and providing staff training on abuse prevention.
Deficiencies (2)
Failed to protect Resident #1 from verbal abuse by CNA A on 02/03/25.
Failed to ensure Resident #1 was free from involuntary seclusion when CNA A pushed the resident into her room, closed and held the door closed while the resident was heard yelling to be let out.
Report Facts
Residents reviewed for abuse: 3
Residents reviewed for involuntary seclusion: 3
Dates of noncompliance: Noncompliance began on 2025-02-03 and ended on 2025-02-07 for abuse, and ended on 2025-02-27 for seclusion.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Agency CNA | Named in findings of verbal abuse and involuntary seclusion of Resident #1. |
| CNA D | Witnessed CNA A's behavior and heard CNA A loudly telling the resident her name repeatedly. | |
| RN B | Registered Nurse | Interviewed regarding the incident and training on abuse prevention. |
| SW | Social Worker | Provided support to Resident #1 and conducted abuse interviews. |
| DON | Director of Nursing | Assessed Resident #1 and interviewed CNA A. |
| ADM | Administrator | Reviewed video evidence, interviewed staff, and coordinated investigation. |
| GM | Staffing Agency General Manager | Informed of abuse allegations and suspension of CNA A. |
| CNA C | Certified Nursing Assistant | Interviewed about the incident and abuse reporting. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Feb 29, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to obtain signed informed consents for psychotropic medications for certain residents and failure to ensure accurate and updated comprehensive care plans for multiple residents.
Complaint Details
The complaint investigation revealed failures in obtaining informed consents for psychotropic medications for Residents #4 and #7, and deficiencies in care plan accuracy and food safety practices.
Findings
The facility failed to obtain signed informed consents for the use of Duloxetine for Resident #4 and Aripiprazole for Resident #7, placing residents at risk of receiving psychotropic medications without informed consent. Additionally, the facility failed to ensure comprehensive care plans were reviewed and revised accurately for 5 residents, resulting in inaccurate medication, code status, diet, cognitive status, and pressure ulcer information. The kitchen also failed to properly cover, label, and date food items, risking foodborne illness.
Deficiencies (4)
Failure to obtain signed informed consent for the use of Duloxetine for Resident #4.
Failure to obtain signed informed consent for the use of Aripiprazole for Resident #7.
Failure to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 5 residents.
Failure to procure food from approved sources and store, prepare, distribute, and serve food in accordance with professional standards, including uncovered, unlabeled, and undated food items in refrigerators and walk-in freezer.
Report Facts
Residents reviewed for informed consent: 5
Residents reviewed for care plans: 16
Pressure ulcers: 2
Medication doses: 60
Medication doses: 30
Medication doses: 5
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 3, 2023
Visit Reason
The document is an annual survey inspection report for The Wesleyan Skilled Nursing and Rehabilitation facility conducted to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection. The level of harm and residents affected are both listed as unknown.
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Dec 9, 2022
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning requirements, specifically focusing on the development and implementation of comprehensive person-centered care plans that include measurable objectives and timeframes to meet residents' mental and psychosocial needs.
Findings
The facility failed to develop comprehensive care plans for activities and preferences for five of 25 residents reviewed, placing residents at risk of not achieving or maintaining their highest practicable psychosocial well-being. Interviews and record reviews showed no care planning for activity preferences despite residents expressing interests in various activities.
Deficiencies (1)
Failure to develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured, specifically lacking care planning for activity preferences and interests for five residents.
Report Facts
Residents reviewed for care planning: 25
Residents affected: 5
BIMS scores: 11
BIMS scores: 12
BIMS scores: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AD | Activity Director | Responsible for completing the activity portion of the MDS assessment and creating activity care plan items |
| DON | Director of Nursing | Oversight of compliance with care plans, stated activities care plans are important |
| MDSN | MDS Nurse | Responsible for ensuring care plans are done in a timely manner, frequently checked care plans |
| CCO | Chief Compliance Officer | Responsible for multidisciplinary creation of care plans and overall compliance |
| ADM | Administrator | Knew activities should be in care plans for long term residents and commented on compliance processes |
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