Inspection Reports for
Wesley Manor Health Center
1555 N MAIN ST, FRANKFORT, IN, 46041
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
162% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
43% occupied
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 11, 2025
Visit Reason
The inspection was conducted due to a complaint investigation related to the improper placement and documentation of a Foley catheter for Resident B, which resulted in urethral trauma and hospital admission.
Complaint Details
This citation relates to Intake 2684620. The complaint involved improper Foley catheter insertion by a nursing student under supervision, resulting in trauma and hospital admission. The complaint was substantiated with findings of actual harm.
Findings
The facility failed to ensure proper documentation and follow-up assessments after Foley catheter placement for Resident B. The catheter was improperly inserted by a nursing student, causing urethral trauma, urinary obstruction, and subsequent hospital admission.
Deficiencies (1)
F 0690: The facility failed to provide appropriate care and documentation for a Foley catheter placement, resulting in urethral trauma to Resident B. The catheter insertion was not properly documented, and follow-up assessments after observing urine changes were not completed.
Report Facts
Residents affected: 3
Residents affected: Few
Urine output: 175
Urine drainage: 1500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Nursing student instructor | Supervised student nurse who inserted the Foley catheter |
Inspection Report
Renewal
Deficiencies: 0
Date: 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
Deficiencies: 2
Date: Jun 3, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident discharge policies and dialysis care services.
Findings
The facility failed to document providing the bed hold policy to a discharged resident and failed to follow physician's orders for peritoneal dialysis for one resident. Both deficiencies were classified as minimal harm and affected few residents.
Deficiencies (2)
F 0628: The facility failed to ensure documentation that the bed hold policy was provided to a resident or their representative at discharge. The deficient practice was corrected prior to the survey start.
F 0698: The facility failed to follow physician's orders for peritoneal dialysis for one resident, including improper use of dialysis solution bags and failure to call the dialysis clinic when required.
Report Facts
Residents affected: 1
Residents affected: 1
Inspection Report
Annual Inspection
Census: 161
Deficiencies: 2
Date: 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).
Complaint Details
Complaints IN00447235, IN00448355, and IN00448646 were investigated with no deficiencies related to the allegations cited.
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.
Deficiencies (2)
Failed to ensure documentation that the bed hold policy was provided to a resident at discharge (Resident 81).
Failed to ensure physician's orders for peritoneal dialysis were followed for one resident (Resident 50).
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
Date: 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
Date: 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.
Deficiencies (1)
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.
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
Date: 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
Routine
Deficiencies: 5
Date: Jun 18, 2024
Visit Reason
Routine state inspection of Wesley Manor Health Center to assess compliance with healthcare regulations including restraint use, injury investigations, nutrition, medication management, and food safety.
Findings
The facility failed to ensure proper consent and monitoring for physical restraints, thorough investigation of injuries, adequate nutrition assistance and weight monitoring, appropriate psychotropic medication management, and safe food storage practices.
Deficiencies (5)
F 0604: The facility failed to ensure consent with medical rationale for use of a merry walker restraint, resulting in three falls with major injuries for one resident.
F 0610: The facility failed to conduct staff interviews during investigation of an injury of unknown source for one resident.
F 0692: The facility failed to cue and assist a resident to eat and did not assess or reweigh after significant weight loss.
F 0758: The facility failed to document resident-specific psychosis or behaviors as rationale for declining gradual dose reduction of an antipsychotic medication.
F 0812: The facility failed to ensure employee meals were not stored in resident refrigerators, failed to label and date opened food items, and failed to maintain refrigerator/freezer thermometers.
Report Facts
Falls with major injuries: 3
Sutures: 12
Weight loss percentage: 5.54
Psychotropic medication dose: 0.75
Psychotropic medication dose reduction request: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding restraint use and consent for Resident 70. |
| Assistant Executive Director | Assistant Executive Director (AED) | Interviewed regarding restraint use, injury investigations, and nutrition concerns. |
| Executive Director | Executive Director (ED) | Interviewed regarding injury investigation for Resident 34. |
| Psychiatric Nurse Practitioner | Psychiatric Nurse Practitioner (NP) | Interviewed regarding psychotropic medication use for Resident 38. |
| Registered Dietitian | Registered Dietitian (RD) | Interviewed regarding nutrition assessment and weight monitoring for Resident 45. |
| RN 3 | Registered Nurse | Interviewed about use and supervision of merry walker restraint. |
| RN 2 | Registered Nurse | Interviewed about uncovered ice cream found in refrigerator. |
| LPN 1 | Licensed Practical Nurse | Interviewed about food storage policy and refrigerator conditions. |
| Assistant Director of Dining | Assistant Director of Dining | Interviewed about refrigerator use and labeling. |
Inspection Report
Annual Inspection
Census: 86
Deficiencies: 5
Date: 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.
Deficiencies (5)
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.
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.
Failure to cue and assist Resident 45 during lunch according to the plan of care and to assess/reweigh for significant weight change.
Failure to provide documentation showing resident specific psychosis/behaviors used as rationale for declining a gradual dose reduction of an antipsychotic for Resident 38.
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.
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
Date: Nov 27, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00418063 completed on September 28, 2023.
Complaint Details
Investigation of Complaint IN00418063 was completed and found corrected.
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.
Report Facts
Census SNF/NF beds: 89
Total census: 89
Medicare census: 3
Medicaid census: 81
Other payor census: 5
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 28, 2023
Visit Reason
The inspection was conducted in response to a complaint regarding a resident fall incident where the facility allegedly failed to use a gait belt during transfer, resulting in injury.
Complaint Details
This Federal Tag relates to Complaint IN00418063. The complaint involved failure to use a gait belt during resident transfer, resulting in a fall and injury.
Findings
The facility failed to protect a resident from injury by not using a gait belt during transfer, leading to a fall and head injury including a laceration and subdural hematoma. Staff interviews and document reviews confirmed the lack of gait belt use despite facility policy and prior education.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and provide adequate supervision to prevent accidents. Resident B fell and sustained a head laceration and subdural hematoma after staff transferred her without using a gait belt as required by policy.
Report Facts
Staples placed: 4
Laceration size: 1.2
Audit dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 4 | Registered Nurse | Assisted with resident transfer and assessment after fall; conducted teachable moment with CNA. |
| CNA 3 | Certified Nursing Assistant | Assisted resident during transfer without using gait belt; signed re-education on gait belt policy. |
| Director of Nursing | Provided education/reminder on gait belt use after incident; involved in policy enforcement. | |
| Assistant Executive Director | Provided facility documents and information on audits and policies. |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 91
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
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.
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
Date: Jul 12, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00412485.
Complaint Details
Complaint IN00412485 was investigated and found to have no deficiencies related to the allegations.
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.
Inspection Report
Renewal
Deficiencies: 0
Date: 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
Date: 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.
Deficiencies (3)
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.
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.
Failed to ensure 12 of 12 fire drills included verification of transmission of fire alarm signal to monitoring station.
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
Date: 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
Routine
Deficiencies: 5
Date: Apr 4, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication self-administration, PASARR assessments, medication labeling, food sanitation, and antibiotic monitoring at Wesley Manor Health Center.
Findings
The facility was found deficient in multiple areas including failure to assess residents for self-administration of medications, incomplete PASARR screenings when new mental health diagnoses and antipsychotic medications were added, failure to label and date insulin pens on medication carts, unsanitary food storage and preparation practices, and lack of monitoring for prophylactic antibiotic use.
Deficiencies (5)
F 0554: The facility failed to ensure a resident was assessed for self-administration of medications before leaving medications unattended with the resident.
F 0644: The facility failed to complete PASARR assessments when new mental health diagnoses and antipsychotic medications were added for residents.
F 0761: The facility failed to label and date insulin pens on 2 of 4 medication carts reviewed during medication storage.
F 0812: The facility failed to store food and wash and dry dishes in a sanitary manner, risking foodborne illness for residents.
F 0881: The facility failed to monitor the prophylactic antibiotic use for a resident, lacking surveillance for appropriateness and outcomes.
Report Facts
Medication pens without open dates: 5
Residents affected: 1
Residents affected: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) 5 | Interviewed regarding leaving medications unattended with Resident 45. | |
| Director of Nursing | Interviewed regarding lack of self-administration assessment and antibiotic monitoring. | |
| Associate Executive Director | Interviewed regarding PASARR assessment deficiencies. | |
| Licensed Practical Nurse (LPN) 2 | Observed medication cart with unlabeled insulin pens. | |
| Licensed Practical Nurse (LPN) 3 | Observed medication cart with unlabeled insulin pen. | |
| Director of Dining Services (DDS) | Interviewed regarding unsanitary food storage and dishwashing. | |
| Kitchen Supervisor (KS) 4 | Interviewed regarding lack of cooling log for mashed potatoes. | |
| Infection Preventionist | Interviewed regarding lack of antibiotic monitoring. |
Inspection Report
Annual Inspection
Census: 75
Capacity: 163
Deficiencies: 7
Date: 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.
Deficiencies (7)
Failed to ensure a resident had been assessed for self-administration of medications before leaving medications unattended.
Failed to ensure PASARR assessments were completed when new mental health diagnoses and antipsychotic medications were added for residents.
Failed to label and date insulin pens on medication carts.
Failed to store food and wash/dry dishes in a sanitary manner, including unclean utensils and improper food storage.
Failed to monitor prophylactic antibiotic use for a resident.
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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