Inspection Report
Renewal
Deficiencies: 0
Jun 24, 2025
Visit Reason
The visit was a paper compliance review related to the Recertification and State Licensure Survey completed on June 3, 2025.
Findings
Wesley Manor Health Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure Survey.
Inspection Report
Annual Inspection
Census: 161
Deficiencies: 2
Jun 3, 2025
Visit Reason
This was a Recertification and State Licensure Survey including a State Residential Licensure Survey and investigation of three complaints (IN00447235, IN00448355, IN00448646).
Findings
No deficiencies were cited related to the complaints investigated. The facility had past noncompliance related to documentation of the bed hold policy for one resident discharged, which was corrected prior to the survey. Another deficiency involved failure to follow physician orders for peritoneal dialysis for one resident, with corrective actions and policy revisions underway.
Complaint Details
Complaints IN00447235, IN00448355, and IN00448646 were investigated with no deficiencies related to the allegations cited.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure documentation that the bed hold policy was provided to a resident at discharge (Resident 81). | SS=D |
| Failed to ensure physician's orders for peritoneal dialysis were followed for one resident (Resident 50). | SS=D |
Report Facts
Survey dates: May 27, 28, 29, 30, and June 2 and 3, 2025
Census Bed Type - SNF/NF: 82
Census Bed Type - Residential: 79
Total Census: 161
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 68
Census Payor Type - Other: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gary Brent Waymire | Executive Director/Administrator | Signed the report and mentioned in interview regarding bed hold policy |
| RN 2 | Interviewed regarding dialysis treatment procedures and orders | |
| Director of Nursing | Director of Nursing | Interviewed regarding dialysis order compliance and documentation |
| Physician | Interviewed regarding dialysis order clarification and follow-up |
Inspection Report
Re-Inspection
Census: 89
Capacity: 179
Deficiencies: 0
Aug 1, 2024
Visit Reason
This visit was for a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on June 18, 2024.
Findings
Wesley Manor Health Center was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey.
Report Facts
Census SNF/NF: 89
Census Residential: 90
Total Capacity: 179
Census Payor Type Medicare: 2
Census Payor Type Medicaid: 48
Census Payor Type Other: 39
Total Census Payor Type: 89
Inspection Report
Life Safety
Census: 92
Capacity: 96
Deficiencies: 1
Jul 2, 2024
Visit Reason
The survey was conducted as a Life Safety Code Recertification and State Licensure survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with Life Safety Code requirements, specifically failing to ensure that 1 of 6 sets of smoke barrier doors would restrict smoke movement for at least 20 minutes. The deficient door left a one-inch gap and affected 16 residents, 4 staff, and 2 visitors.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 6 sets of smoke barrier doors would restrict the movement of smoke for at least 20 minutes, leaving a one-inch gap when closed. | SS=E |
Report Facts
Certified beds: 96
Census: 92
Barrier doors inspected: 6
Residents affected: 16
Staff affected: 4
Visitors affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gary Brent Waymire | Executive Director/Administrator | Signed the report |
| Maintenance Supervisor | Interviewed during observation of deficient door; no full name provided |
Inspection Report
Life Safety
Deficiencies: 0
Jul 2, 2024
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey conducted on 07/02/24.
Findings
Wesley Manor Health Center was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Annual Inspection
Census: 86
Deficiencies: 5
Jun 18, 2024
Visit Reason
This was a Recertification and State Licensure Survey including a State Residential Licensure Survey conducted on June 12, 13, 14, 17 and 18, 2024.
Findings
The facility was found to have deficiencies related to physical restraints, investigation of injuries, nutrition and hydration, psychotropic medication use, and food safety practices. The facility submitted plans of correction addressing these issues and was found in compliance with state residential licensure requirements.
Severity Breakdown
SS=G: 1
SS=D: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure a consent with the identified medical reason for the use of a restraint was completed at the initiation of the restraint, resulting in Resident 70 sustaining three falls with major injuries while using a merry walker restraint. | SS=G |
| Failure to ensure a thorough investigation was completed including staff interviews after an injury of unknown source for Resident 34 with an acute right hip fracture. | SS=D |
| Failure to cue and assist Resident 45 during lunch according to the plan of care and to assess/reweigh for significant weight change. | SS=D |
| Failure to provide documentation showing resident specific psychosis/behaviors used as rationale for declining a gradual dose reduction of an antipsychotic for Resident 38. | SS=D |
| Failure to ensure employee meals were not stored in nutrition refrigerators, items were dated and labeled with owner and open dates, and thermometers were present in refrigerators/freezers for safe and sanitary food storage. | SS=D |
Report Facts
Survey dates: 5
Resident census: 86
Falls with injury: 3
Weight change: 5.54
Psychotropic dose: 0.75
Psychotropic dose reduction request: 0.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gary Brent Waymire | Executive Director / Administrator | Signed the report |
| RN 3 | Interviewed regarding Resident 70's use of merry walker restraint | |
| Director of Nursing | Interviewed regarding restraint use and investigation findings | |
| Assistant Executive Director | Interviewed regarding restraint use and investigation findings | |
| LPN 1 | Interviewed regarding food storage and refrigerator conditions | |
| Registered Dietitian | Interviewed regarding Resident 45's nutrition and weight monitoring | |
| Psychiatric Nurse Practitioner | Interviewed regarding Resident 38's psychotropic medication use and behaviors | |
| Assistant Director of Dining | Interviewed regarding food storage practices | |
| RN 2 | Interviewed regarding uncovered ice cream found in refrigerator |
Inspection Report
Follow-Up
Census: 89
Capacity: 89
Deficiencies: 0
Nov 27, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00418063 completed on September 28, 2023.
Findings
Wesley Manor Health Center was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Investigation of Complaint IN00418063. The complaint was corrected.
Complaint Details
Investigation of Complaint IN00418063 was completed and found corrected.
Report Facts
Census SNF/NF beds: 89
Total census: 89
Medicare census: 3
Medicaid census: 81
Other payor census: 5
Inspection Report
Complaint Investigation
Census: 91
Capacity: 91
Deficiencies: 1
Sep 28, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00418063 regarding allegations of deficiencies related to resident safety and supervision.
Findings
The facility failed to protect a resident (Resident B) from injury by not using a gait belt during transfer, resulting in a fall with head injury and subdural hematoma. The facility acknowledged the deficiency and implemented corrective actions including staff re-education and audits.
Complaint Details
Complaint IN00418063 was substantiated with federal/state deficiencies cited at F689 related to failure to use gait belt during resident transfer causing a fall and injury.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure the resident environment remained free of accident hazards and failure to provide adequate supervision and assistance devices to prevent accidents, specifically not using a gait belt during resident transfer. | SS=G |
Report Facts
Census: 91
Total Capacity: 91
Medicare Census: 4
Medicaid Census: 82
Other Payor Census: 5
Staple count: 4
Laceration size: 1.2
Audit frequency: 10
Audit frequency: 8
Audit frequency: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gary Brent Waymire | Executive Director / Administrator | Signed the report |
| RN 4 | Registered Nurse | Assessed resident after fall and assisted with transfer using gait belt |
| CNA 1 | Certified Nurse’s Aide | Assisted resident without using gait belt, re-educated after incident |
| CNA 3 | Certified Nurse’s Aide | Involved in transfer during fall, did not use gait belt |
| Director of Nursing | Provided staff re-education on gait belt use and policy | |
| Assistant Executive Director | Provided interviews and documents related to audits and policies |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 0
Jul 12, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00412485.
Findings
No deficiencies related to the allegations in Complaint IN00412485 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Complaint Details
Complaint IN00412485 was investigated and found to have no deficiencies related to the allegations.
Inspection Report
Renewal
Deficiencies: 0
May 19, 2023
Visit Reason
Paper compliance review to the Recertification and Licensure Survey completed on April 4, 2023.
Findings
Wesley Manor Health Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review for the Recertification and Licensure Survey.
Inspection Report
Life Safety
Census: 86
Capacity: 96
Deficiencies: 3
Apr 20, 2023
Visit Reason
A Life Safety Code Recertification and State Licensure survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code.
Findings
The facility was found not in compliance with Life Safety Code requirements, including issues with vertical openings enclosure, corridor doors, and fire drills. Specific deficiencies included a fire door that failed to fully close and latch, a corridor door propped open with a kick stop, and lack of documentation verifying transmission of fire alarm signals during drills.
Severity Breakdown
SS=E: 2
SS=F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure protection of 1 of 2 vertical openings with required 1-hour fire resistance rating; elevator separation door failed to fully close and latch leaving a 1-inch gap. | SS=E |
| Failed to ensure 1 of over 100 corridor doors had means suitable for keeping the door closed, no impediment to closing, latching, and resisting passage of smoke; kitchen door propped open with a kick stop. | SS=E |
| Failed to ensure 12 of 12 fire drills included verification of transmission of fire alarm signal to monitoring station. | SS=F |
Report Facts
Certified beds: 96
Census: 86
Residents potentially affected by vertical opening deficiency: 18
Staff potentially affected by vertical opening deficiency: 6
Visitors potentially affected by vertical opening deficiency: 2
Residents potentially affected by corridor door deficiency: 30
Staff potentially affected by corridor door deficiency: 10
Visitors potentially affected by corridor door deficiency: 2
Fire drills missing verification: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gary Brent Waymire | Executive Director / Administrator | Signed report and referenced as Maintenance Director interviewed during survey |
Inspection Report
Life Safety
Deficiencies: 0
Apr 20, 2023
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey was conducted on 04/20/23 and completed on 05/08/23.
Findings
Wesley Manor Health Center was found in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Annual Inspection
Census: 75
Capacity: 163
Deficiencies: 7
Apr 4, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted on March 29, 30, 31 and April 3 and 4, 2023.
Findings
The facility was found deficient in multiple areas including failure to assess residents for self-administration of medications, incomplete PASARR assessments, unlabeled insulin pens, unsanitary food storage and preparation practices, lack of monitoring for prophylactic antibiotic use, unsigned resident service plans, and failure of kitchen staff to wear proper hair restraints.
Severity Breakdown
SS=D: 4
SS=F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure a resident had been assessed for self-administration of medications before leaving medications unattended. | SS=D |
| Failed to ensure PASARR assessments were completed when new mental health diagnoses and antipsychotic medications were added for residents. | SS=D |
| Failed to label and date insulin pens on medication carts. | SS=D |
| Failed to store food and wash/dry dishes in a sanitary manner, including unclean utensils and improper food storage. | SS=F |
| Failed to monitor prophylactic antibiotic use for a resident. | SS=D |
| Failed to ensure resident service plans were signed and dated by residents. | — |
| Failed to ensure kitchen staff wore hair restraints completely covering their hair in food preparation areas. | — |
Report Facts
Survey dates: 5
Census SNF/NF beds: 88
Census Residential beds: 75
Total licensed capacity: 163
Medicare census: 9
Medicaid census: 68
Other payor census: 11
Number of residents reviewed for service plans: 5
Number of medication carts reviewed: 4
Number of medication pens unlabeled: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gary Brent Waymire | Executive Director / Administrator | Signed the inspection report |
| LPN 5 | Licensed Practical Nurse | Named in medication self-administration deficiency for leaving medications unattended |
| Director of Nursing | Interviewed regarding medication self-administration and antibiotic stewardship deficiencies | |
| Associate Executive Director | Interviewed regarding PASARR assessment deficiencies | |
| LPN 2 | Licensed Practical Nurse | Observed with unlabeled insulin pens on medication cart |
| LPN 3 | Licensed Practical Nurse | Observed with unlabeled insulin pen on medication cart |
| Director of Dining Services | Interviewed and responsible for food safety and sanitation deficiencies | |
| Kitchen Supervisor 4 | Interviewed regarding food safety and sanitation deficiencies | |
| RN 1 | Registered Nurse | Interviewed regarding resident service plan signatures |
| Kitchen Employee 3 | Observed without hair restraint in kitchen | |
| Kitchen Employee 4 | Observed without hair restraint in kitchen |
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