Inspection Reports for Wesleyan Health Care Center
729 WEST 35TH ST, IN, 46953
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Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 0
Jun 23, 2025
Visit Reason
This visit was conducted for the Investigation of Complaint IN00461911.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00461911 found no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF/NF: 104
Census Bed Type - Residential: 6
Census Bed Type - Total: 110
Census Payor Type - Medicare: 7
Census Payor Type - Medicaid: 63
Census Payor Type - Other: 34
Census Payor Type - Total: 104
Inspection Report
Complaint Investigation
Census: 103
Capacity: 103
Deficiencies: 0
May 23, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00458790.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00458790 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 6
Medicaid census: 57
Other payor census: 25
Inspection Report
Complaint Investigation
Census: 101
Capacity: 108
Deficiencies: 0
Apr 10, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00457092.
Findings
No deficiencies related to the complaint allegation were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00457092 was investigated and found to have no deficiencies related to the allegation.
Report Facts
Census SNF/NF beds: 101
Census Residential beds: 7
Total licensed capacity: 108
Census Payor Type Medicare: 7
Census Payor Type Medicaid: 63
Census Payor Type Other: 24
Total Census Payor Type: 101
Inspection Report
Re-Inspection
Census: 107
Capacity: 169
Deficiencies: 0
Feb 17, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 01/13/25 was performed to verify compliance with prior deficiencies.
Findings
At this PSR Life Safety Code survey, Wesleyan Health Care Center was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and applicable state and national fire safety codes.
Inspection Report
Re-Inspection
Census: 100
Capacity: 105
Deficiencies: 0
Jan 31, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey and Investigation of Complaint IN00448390 completed on December 17, 2024.
Findings
Wesleyan Health Care 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 and Investigation of Complaint IN00448390.
Complaint Details
Complaint IN00448390 - Corrected.
Report Facts
Census SNF/NF: 100
Census Residential: 5
Total Census: 100
Total Capacity: 105
Medicare Census: 5
Medicaid Census: 57
Other Payor Census: 38
Inspection Report
Life Safety
Census: 92
Capacity: 169
Deficiencies: 4
Jan 13, 2025
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) and related NFPA codes.
Findings
The facility was found not in compliance with Life Safety Code requirements, with deficiencies including obstructed exit discharge due to snow, sprinkler head obstruction in the kitchen freezer, lack of ground fault circuit interrupter (GFCI) protection at a wet location near a fish tank, and failure to conduct required maintenance and documentation for Patient Care Related Electrical Equipment (PCREE).
Severity Breakdown
SS=E: 3
SS=F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure 1 of over 4 exit discharges had a level walking surface, free of obstructions, and constructed of hard packed all-weather travel surface; exit near resident room #80 was covered in snow. | SS=E |
| Failed to ensure the spray pattern for sprinkler heads were not obstructed in the kitchen freezer by storage stacked within 18 inches of the ceiling. | SS=E |
| Failed to ensure 1 of over 10 wet locations were provided with ground fault circuit interrupter (GFCI) protection; electric receptacle near large fish tank was not GFCI protected. | SS=E |
| Failed to conduct required maintenance and maintain complete documentation of inspections for Patient Care Related Electrical Equipment (PCREE). | SS=F |
Report Facts
Facility capacity: 169
Census: 92
Exit discharges: 4
Residents potentially affected: 12
Staff potentially affected: 3
Wet locations evaluated: 10
Residents potentially affected: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Debra Smith | Laboratory Director or Provider/Supplier Representative | Signed the report |
| Director of Plant Operations (DOPO) | Interviewed and acknowledged findings related to exit discharge, sprinkler obstruction, GFCI receptacle, and PCREE testing | |
| Corporate Director of Property (CDOP) | Interviewed and acknowledged findings related to exit discharge, sprinkler obstruction, GFCI receptacle, and PCREE testing | |
| Executive Director (ED) | Interviewed and acknowledged findings related to exit discharge, sprinkler obstruction, GFCI receptacle, and PCREE testing |
Inspection Report
Annual Inspection
Census: 105
Deficiencies: 7
Dec 17, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey and Investigation of Complaint IN00448390. This visit included a State Residential Licensure Survey.
Findings
The facility was found deficient in multiple areas including failure to ensure call lights were within reach, failure to maintain a homelike environment due to unrepaired wall damage, failure to provide grooming assistance, failure to ensure two staff assisted with bed mobility resulting in a resident fall and fracture, failure to arrange dental services for a resident who lost dentures, failure to follow infection prevention and control strategies for COVID-19 isolation precautions, and failure to have the most recent State Survey results readily available to the public.
Complaint Details
Complaint IN00448390 - Federal/State deficiencies related to the allegations are cited at F790.
Severity Breakdown
SS=D: 5
SS=G: 1
: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure a resident's call light was within reach. | SS=D |
| Failed to maintain a homelike environment by failing to repair a damaged wall. | SS=D |
| Failed to provide daily grooming assistance for a resident. | SS=D |
| Failed to ensure services for bed mobility were provided with two staff members present, resulting in a resident fall and fracture. | SS=G |
| Failed to arrange dental appointments for a resident who misplaced or lost their dentures. | SS=D |
| Failed to ensure infection prevention and control strategies for transmission-based precautions were followed for residents on COVID-19 isolation. | SS=D |
| Failed to have the most recent State Survey results readily available to the public. | — |
Report Facts
Survey dates: 5
Census SNF/NF beds: 98
Census Residential beds: 7
Total Census: 105
Medicare census: 6
Medicaid census: 55
Other payor census: 37
Number of residents reviewed for call light deficiency: 3
Number of residents reviewed for environment deficiency: 3
Number of residents reviewed for ADL grooming deficiency: 3
Number of residents reviewed for bed mobility deficiency: 3
Number of residents reviewed for dental services deficiency: 1
Number of residents reviewed for infection control deficiency: 2
Number of residents in assisted living: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Debra Smith | RN DCS | Signed the report |
| LPN 11 | Interviewed regarding call light placement for Resident 39 | |
| Director of Nursing | DON | Interviewed regarding call light policy and bed mobility assistance |
| CNA 4 | Involved in Resident 99 fall incident and interviewed about bed mobility assistance | |
| RN 5 | Interviewed regarding Resident 99 fall and care | |
| Social Services Director | SSD | Interviewed regarding dental services for Resident B |
| LPN 20 | Interviewed regarding Resident B's dentures | |
| Corporate Nurse | Provided facility policies and interviewed about dental services and infection control | |
| QMA 13 | Interviewed regarding COVID-19 isolation precautions | |
| RN 12 | Observed donning PPE for COVID-19 isolation | |
| CNA 15 | Observed incorrectly donning PPE for COVID-19 isolation | |
| LPN 3 | Observed and corrected PPE donning for CNA 15 |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 100
Deficiencies: 0
Oct 17, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00441835.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00441835 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type Total: 100
Census Present: 94
Census Payor Type Medicare: 5
Census Payor Type Medicaid: 52
Census Payor Type Other: 37
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 0
Aug 9, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00440546.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00440546 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 93
Medicare residents: 7
Medicaid residents: 53
Other payor residents: 33
Inspection Report
Re-Inspection
Census: 101
Deficiencies: 0
Jun 19, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00432015 and IN00432308, which also resulted in an unrelated deficiency cited, completed on May 6, 2024.
Findings
Wesleyan Health Care 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 Complaints IN00432015 and IN00432308 and the unrelated deficiency cited during the investigation.
Complaint Details
Complaints IN00432015 and IN00432308 were investigated and found to be corrected.
Report Facts
Census Bed Type Total: 101
Census Payor Type Total: 95
SNF/NF Beds: 94
SNF Beds: 1
Residential Beds: 6
Medicare Residents: 6
Medicaid Residents: 56
Other Payor Residents: 33
Inspection Report
Life Safety
Census: 97
Capacity: 169
Deficiencies: 0
May 15, 2024
Visit Reason
A Life Safety Code Preoccupancy Survey was conducted due to remodeling at the facility to accommodate the creation of a six-bay dialysis unit and related renovations.
Findings
The facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility is fully sprinklered with appropriate fire alarm systems and the separation wall between the Nursing Facility and Assisted Living Hall has a one-hour fire rating as required.
Report Facts
Facility capacity: 169
Census: 97
Inspection Report
Complaint Investigation
Census: 6
Deficiencies: 0
May 6, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00433127 and related complaints IN00432015 and IN00432308.
Findings
No deficiencies were found related to Complaint IN00433127. Federal/State deficiencies were cited related to complaints IN00432015 and IN00432308. Unrelated deficiencies were also cited.
Complaint Details
Complaint IN00433127 was found to have no deficiencies related to the allegations. Complaints IN00432015 and IN00432308 had Federal/State deficiencies cited at F684 and F690 respectively.
Report Facts
Residential Census: 6
Inspection Report
Re-Inspection
Census: 102
Capacity: 169
Deficiencies: 0
Jan 25, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 01/03/24.
Findings
At this Post Survey Revisit, Wesleyan Health Care Center was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers.
Inspection Report
Annual Inspection
Census: 92
Capacity: 169
Deficiencies: 4
Jan 3, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with federal regulations and state law on 01/03/2024.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements, Life Safety Code requirements including smoke barrier penetrations, ground fault circuit interrupter (GFCI) protection in wet locations, emergency generator battery backup lighting, and proper storage and securing of oxygen cylinders.
Severity Breakdown
Level E: 3
Level F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 1 emergency task generator battery backup lights was maintained and working. | Level F |
| Failed to ensure penetrations through 1 of 1 smoke barrier wall was protected to maintain smoke resistance, with a 2" by 4" unsealed gap. | Level E |
| Failed to ensure 3 of over 10 wet locations were provided with ground fault circuit interrupter (GFCI) protection against electric shock. | Level E |
| Failed to ensure 3 of 20 cylinders of nonflammable gases such as oxygen were properly secured from falling. | Level E |
Report Facts
Facility capacity: 169
Census: 92
Deficiencies cited: 4
Oxygen cylinders improperly secured: 3
Wet locations without GFCI protection: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Debra Smith | RN, DCS | Director of Plant Operations and provider/supplier representative involved in observations and interviews related to deficiencies |
Inspection Report
Recertification
Census: 96
Capacity: 102
Deficiencies: 6
Dec 4, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey and Investigation of Complaints IN00422812 and IN00421594. This visit included a State Residential Licensure Survey.
Findings
The facility had multiple deficiencies including failure to ensure the activity director met qualifications, failure to implement fall risk care plans, failure to ensure appropriate use of psychotropic medications, insufficient infection preventionist staffing, failure to offer updated pneumococcal vaccinations, and unsanitary laundry equipment.
Complaint Details
Complaint IN00422812 - No deficiencies related to the allegations are cited. Complaint IN00421594 - No deficiencies related to the allegations are cited.
Severity Breakdown
SS=E: 1
SS=D: 3
SS=F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure the activity director completed the required education to meet qualifications. | SS=E |
| Failed to implement care plan interventions to reduce fall risk for 1 of 3 residents reviewed for accidents. | SS=D |
| Failed to ensure a resident did not receive an antipsychotic without an indication of use for 1 of 5 residents reviewed for unnecessary medications. | SS=D |
| Failed to ensure the Infection Preventionist had sufficient time to perform responsibilities, requiring the full-time DON to assume the role. | SS=F |
| Failed to ensure residents received accurate, up-to-date information on pneumococcal vaccinations and offer the new PCV 20 vaccine. | SS=D |
| Failed to ensure sanitary condition of laundry equipment used by residents; dried brown substance observed on washer rim. | — |
Report Facts
Facility census: 96
Total licensed capacity: 102
Residents receiving antipsychotic medications: 5
Residents reviewed for fall risk: 3
Residents reviewed for immunizations: 5
Inspection Report
Annual Inspection
Deficiencies: 0
Dec 4, 2023
Visit Reason
The visit was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Wesleyan Health Care 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 of the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 99
Capacity: 105
Deficiencies: 0
Nov 9, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00420321.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00420321 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF/NF: 98
Census Bed Type - SNF: 1
Census Bed Type - Residential: 6
Total Capacity: 105
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 62
Census Payor Type - Other: 32
Total Census: 99
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 2, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00417630 completed on October 12, 2023.
Findings
Wesleyan Health Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Complaint Investigation.
Complaint Details
Investigation of Complaint IN00417630 completed with compliance found.
Inspection Report
Complaint Investigation
Census: 99
Capacity: 99
Deficiencies: 1
Oct 12, 2023
Visit Reason
This visit was for the investigation of Complaint IN00417630 related to federal and state deficiencies concerning insulin administration.
Findings
The facility failed to ensure timely administration of insulin per physician orders for 4 of 4 residents reviewed. Multiple instances of late or missed insulin doses were documented, and interviews with residents and staff confirmed delays and documentation issues.
Complaint Details
Complaint IN00417630 - Federal/State deficiencies related to the allegations are cited at F684.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure timely administration of insulin per physician orders for 4 residents. | SS=E |
Report Facts
Census: 99
Total Capacity: 99
Residents receiving insulin reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Debra Smith | DCS | Laboratory Director's or Provider/Supplier Representative's signature on report |
| QMA 12 | Interviewed regarding medication administration workload | |
| RN 4 | Registered Nurse | Interviewed regarding insulin administration practices |
| LPN 13 | Licensed Practical Nurse | Interviewed regarding medication documentation and administration |
| DON | Director of Nursing | Interviewed regarding staff medication administration and documentation practices |
Inspection Report
Follow-Up
Census: 102
Capacity: 107
Deficiencies: 0
Sep 7, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00414590 completed on 2023-08-11.
Findings
Wesleyan Health Care 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 Investigation of Complaint IN00414590.
Complaint Details
Complaint IN00414590 - Corrected.
Report Facts
Census Bed Type - SNF/NF: 100
Census Bed Type - SNF: 2
Census Bed Type - Residential: 5
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 63
Census Payor Type - Other: 34
Inspection Report
Complaint Investigation
Census: 95
Capacity: 95
Deficiencies: 1
Aug 10, 2023
Visit Reason
This visit was conducted for the investigation of three complaints (IN00413106, IN00413966, and IN00414590). No deficiencies were cited for the first two complaints, but a federal/state deficiency related to complaint IN00414590 was cited at F689.
Findings
The facility failed to ensure adequate supervision during dining for one resident (Resident B), resulting in a choking incident that required hospitalization and ventilator placement. The investigation revealed that Resident B was served a meal inconsistent with his prescribed pureed diet, and staff supervision during the meal was inadequate.
Complaint Details
Complaint IN00414590 was substantiated with a federal/state deficiency cited at F689 related to inadequate supervision during dining leading to a choking incident. Complaints IN00413106 and IN00413966 had no deficiencies related to the allegations.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure supervision during dining for 1 of 4 residents reviewed for accidents, resulting in choking and hospitalization. | SS=G |
Report Facts
Census: 95
Total Capacity: 95
Residents reviewed for accidents: 4
Medicare residents: 4
Medicaid residents: 61
Other payor residents: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Debra Smith | RN DCS | Facility representative who provided speech therapy evaluation and signed report |
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 0
Jul 5, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00411343.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00411343 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 91
Census Bed Type: 90
Census Bed Type: 1
Census Payor Type: 2
Census Payor Type: 60
Census Payor Type: 29
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 0
May 24, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00408663.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00408663 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 101
Census Bed Type - SNF/NF: 94
Census Bed Type - SNF: 7
Census Payor Type - Medicare: 7
Census Payor Type - Medicaid: 56
Census Payor Type - Other: 38
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 0
May 1, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00407428 and IN00406789 and included a COVID-19 Focused Infection Control Survey.
Findings
No deficiencies related to the allegations in complaints IN00407428 and IN00406789 were cited. The facility was found to be in compliance with relevant federal and state regulations regarding the complaints and the COVID-19 survey.
Complaint Details
Complaint IN00407428 and Complaint IN00406789 were investigated with no deficiencies related to the allegations cited.
Report Facts
Census: 94
Census SNF/NF beds: 92
Census SNF beds: 2
Census Medicare residents: 5
Census Medicaid residents: 60
Census Other payor residents: 29
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 0
Mar 10, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00399270.
Findings
No deficiencies related to the allegations were cited. Wesleyan Health Care 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 Investigation of Complaint IN00399270.
Complaint Details
Complaint IN00399270 - No deficiencies related to the allegations are cited.
Report Facts
Census Bed Type: 99
Census Payor Type: 99
SNF/NF beds: 96
SNF beds: 3
Medicare residents: 11
Medicaid residents: 62
Other payor residents: 26
Inspection Report
Re-Inspection
Census: 98
Capacity: 169
Deficiencies: 0
Jan 20, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 11/29/22 was performed to verify compliance.
Findings
At this PSR survey, Wesleyan Health Care Center was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 483.90(a).
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 0
Jan 10, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00425323.
Findings
No deficiencies related to the allegations were cited. Wesleyan Health Care 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 complaint investigation.
Complaint Details
Complaint IN00425323 - No deficiencies related to the allegations are cited.
Report Facts
Census: 95
Census Bed Type - SNF: 1
Census Bed Type - SNF/NF: 94
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 59
Census Payor Type - Other: 33
Inspection Report
Complaint Investigation
Census: 104
Capacity: 111
Deficiencies: 0
Dec 21, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00394549.
Findings
The complaint IN00394549 was found to be unsubstantiated due to lack of evidence. Wesleyan Health Care 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 investigation.
Complaint Details
Complaint IN00394549 - Unsubstantiated due to lack of evidence.
Report Facts
Census Bed Type Total: 111
Census Payor Type Total: 104
Medicare Census: 11
Medicaid Census: 65
Other Payor Census: 28
Inspection Report
Life Safety
Census: 100
Capacity: 169
Deficiencies: 11
Nov 29, 2022
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with federal regulations.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Multiple deficiencies were identified related to fire safety, door hardware, fire barriers, cooking equipment shutoff access, fire alarm system operation, corridor door integrity, electrical equipment use, and gas cylinder storage.
Severity Breakdown
SS=E: 7
SS=F: 1
SS=D: 4
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to maintain latching hardware on 1 of 1 smoke barrier doors in the Business hall southeast. | SS=E |
| Failed to ensure the penetration in 1 of 1 fire barrier walls that separated health care from assisted living was maintained to ensure fire resistance. | SS=E |
| Failed to ensure the means of egress through 3 of 3 exit doors were readily accessible without requiring a tool or key; codes to open doors were not posted. | SS=E |
| Failed to ensure staff had access to the shutoff switch for 1 of 1 cook tops in the therapy gym. | SS=E |
| Failed to ensure staff had access to the shutoff switch for 1 of 1 cook tops in the Assisted Living activity room. | SS=E |
| Failed to ensure 1 of 1 fire alarm systems was continuously in proper operating condition; fire alarm control panel had incorrect time and date. | SS=F |
| Failed to ensure 1 of 10 service corridor doors resist the passage of smoke and are capable of resisting fire for 20 minutes; door had a half inch hole. | SS=D |
| Failed to ensure 1 of 1 flexible cords were installed properly and used in a safe manner; power strip dangling unsecured in resident room 59. | SS=D |
| Failed to ensure 1 of 1 power strips for non-PCREE in resident rooms met UL 1363 standards. | SS=D |
| Failed to ensure 1 of 1 flexible cords were not used as a substitute for fixed wiring; extension cord used in Activity room. | SS=D |
| Failed to ensure 3 of over 20 cylinders of nonflammable gases such as oxygen were properly secured from falling. | SS=E |
Report Facts
Facility capacity: 169
Census: 100
Deficiencies cited: 11
Oxygen cylinders improperly stored: 3
Exit doors with locking issues: 3
Service corridor doors with smoke passage issues: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Monica Martin | Executive Director | Signed the report |
| Director of Plant Operations | Interviewed and involved in observations related to fire safety, door hardware, cooking equipment, fire alarm system, and electrical equipment | |
| Maintenance Director | Acknowledged oxygen cylinder storage deficiencies |
Inspection Report
Annual Inspection
Deficiencies: 0
Nov 7, 2022
Visit Reason
The visit was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Wesleyan HealthCare 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: 92
Capacity: 98
Deficiencies: 1
Oct 24, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted from October 18 to 24, 2022.
Findings
The facility was found to have a deficiency related to inadequate supervision to prevent falls for one resident, Resident 8, who had multiple falls with no updated care plan interventions after each fall. The facility was found to be in compliance with State Residential Licensure Survey requirements.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide adequate supervision to prevent falls for 1 of 4 residents reviewed (Resident 8). | SS=D |
Report Facts
Survey dates: 5
Census Bed Type Total: 98
Census Payor Type Total: 92
Resident falls: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Debra Smith | RN, DCS | Laboratory Director's or Provider/Supplier Representative's signature on report |
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 0
Sep 12, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00389051.
Findings
The complaint IN00389051 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00389051 was investigated and found unsubstantiated due to lack of evidence.
Report Facts
Census Bed Type Total: 95
Census Payor Type Medicare: 9
Census Payor Type Medicaid: 65
Census Payor Type Other: 21
Inspection Report
Complaint Investigation
Census: 106
Capacity: 106
Deficiencies: 2
Aug 16, 2022
Visit Reason
This visit was for the investigation of complaints IN00387608 and IN00387631, both substantiated with related federal/state deficiencies cited.
Findings
The facility failed to prevent resident-to-resident abuse for 2 of 4 residents reviewed and failed to provide adequate supervision to prevent a cognitively impaired resident from ingesting ear cleaner solution. Multiple incidents of resident altercations and inadequate supervision were documented.
Complaint Details
Complaint IN00387608 - Substantiated. Complaint IN00387631 - Substantiated.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to prevent resident-to-resident abuse for 2 of 4 residents reviewed (Resident B and Resident G). | SS=D |
| Failed to provide adequate supervision for a cognitively impaired resident from ingesting ear cleaner solution (Resident B). | SS=D |
Report Facts
Census: 106
Licensed Capacity: 106
Residents on 15-minute checks: 1
Audit frequency: 4
Audit frequency: 3
Audit frequency: 2
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 16, 2022
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of complaints IN00387608 and IN00387631.
Findings
Wesleyan Health Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Complaint Details
The visit was related to complaint investigations IN00387608 and IN00387631. The facility was found to be in compliance.
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