Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wesley Manor Health Center during CMS and state inspections, most recent first.
A resident with chronic respiratory failure with hypoxia, emphysema, and HTN was observed resting in bed with six pills in a cup at the bedside and no staff present. The record did not contain an IDT assessment, physician order, or care plan for self-administration of meds, and an LPN stated she was not aware whether the resident could self-administer. The DON said she was aware of the concern.
A resident with respiratory failure with hypoxia and emphysema was observed receiving oxygen via nasal cannula at 3.5 lpm while resting, despite a physician order for 2 lpm at rest and 5 lpm with exertion. The care plan directed oxygen settings to follow the physician's order, but CNA reported the resident was on 3 lpm and the DON stated she did not know the ordered oxygen amount.
A resident with multiple medical conditions suffered urethral trauma and urinary obstruction after a foley catheter was improperly inserted by a nursing student. The facility failed to document the catheter procedure, did not specify catheter details in the physician's order, and did not follow up on abnormal urine characteristics or the resident's complaints of pain. The lack of documentation and assessment led to the resident's hospitalization for catheter-related injury.
A resident with multiple medical conditions was discharged to the hospital, but there was no documentation that the required bed hold policy was provided to the resident or their representative at the time of discharge, nor evidence it was sent by email or mail as required by facility policy.
A resident with end stage renal disease did not receive peritoneal dialysis care in accordance with physician orders, as staff failed to consistently use the correct dialysis solution bags based on systolic blood pressure and did not contact the dialysis clinic when the resident's weight exceeded the specified threshold. Documentation of bag concentrations and required communications was also incomplete.
A resident with severe cognitive impairment and a history of falls was placed in a merry walker, considered a restraint, without proper consent or documentation. The facility failed to reassess the appropriateness of the restraint after the resident experienced three falls with major injuries, resulting in emergency room visits and facial fractures. Interviews revealed reliance on verbal discussions rather than documented consent and assessments, highlighting a deficiency in the facility's adherence to its restraint use policy.
A resident with Alzheimer's and reduced mobility suffered an acute hip fracture, potentially due to the use of a Maxi lift. The facility failed to conduct a thorough investigation, including staff interviews, to determine the cause of the injury, and did not follow its policy on investigating potential risks.
A resident with dementia and other health issues was not assisted or cued to eat during meals, contrary to their care plan. Over several days, the resident was observed with untouched meals and no staff assistance, leading to a significant weight loss of 5.54% in four days. The facility failed to document a re-weight or assess the weight change, and the resident was not placed on the Nutrition at Risk list, contrary to facility policies.
A facility failed to document sufficient justification for declining a gradual dose reduction of an antipsychotic medication for a resident with dementia and psychotic disorder. Despite a pharmacy request to reduce the dose, the physician declined, citing intermittent delusions, but no such behaviors were documented in the clinical records. The facility's policy requires documentation of behaviors and interventions, which was not adequately followed.
The facility failed to ensure proper food storage and labeling in its nutrition refrigerators, leading to unsanitary conditions. An LPN's lunch was found in a refrigerator designated for specific items, and other items were found without labels or dates. Staff were unaware of the facility's policies, which required labeling, dating, and daily temperature checks.
Missing Self-Administration Medication Assessment and Orders
Penalty
Summary
The facility failed to ensure an IDT assessment, physician’s order, and care plan were in place before a resident self-administered medications. During an observation on 5/14/26 at 10:30 a.m., Resident 7 was resting in bed with her eyes closed, and a cup containing six pills was observed on the bedside table with no staff present in the room. Resident 7’s clinical record, reviewed on 5/18/26, listed diagnoses including chronic respiratory failure with hypoxia, emphysema, and hypertension, but did not contain an IDT assessment, physician’s order, or care plan related to self-administration of medications. An LPN stated on 5/14/26 at 10:35 a.m. that there were six pills left at the bedside and she was not aware whether Resident 7 was able to self-administer her medications. The DON stated on 5/14/26 at 3:05 p.m. that she was aware of the concern.
Failure to Follow Physician's Oxygen Order
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not followed when the facility failed to ensure a physician's oxygen order was carried out for Resident 7. Resident 7 had diagnoses including respiratory failure with hypoxia, emphysema, and hypertension. The care plan stated that oxygen settings were to be according to the physician's order, and a physician's order dated 7/1/25 directed oxygen via nasal cannula at 2 lpm while at rest and 5 lpm with exertion. During observations on 5/14/26 and again on 5/18/26, Resident 7 was receiving oxygen via nasal cannula at 3.5 lpm while resting in bed. During interview, CNA 3 stated the resident was on 3 lpm of oxygen, and the DON stated she did not know what amount of oxygen the resident was supposed to be receiving. The facility policy stated oxygen is administered consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences.
Failure to Document and Assess Foley Catheter Placement Resulting in Urethral Trauma
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, cognitive communication deficit, benign prostatic hyperplasia, and dysuria experienced improper foley catheter care. The facility failed to document the placement of a new foley catheter and did not complete follow-up assessments after a change in urine characteristics was observed. The catheter was inserted by a nursing student under supervision, but neither the student nor the supervising nurse documented the procedure in the resident's medical record. The physician's order for the catheter change did not specify the type, size, or balloon fluid amount, and there was no documentation of the resident's tolerance, urine return, or urine color at the time of insertion. After the catheter change, the resident exhibited signs of complications, including low urine output and red-colored urine, but there was no documentation that the physician was notified of these changes. Later, the resident complained of abdominal pain, and blood was noted in the catheter bag. The resident was subsequently sent to the emergency room, where it was determined that the catheter had been incorrectly placed, resulting in urethral trauma and urinary obstruction. The hospital found the catheter balloon had been inflated in the urethra rather than the bladder, causing a traumatic injury and significant hematuria. The care plan for the resident did not include interventions to prevent pulling on the catheter, despite observations of the resident handling the catheter bag. Facility policy required documentation of catheter size, balloon size, and resident tolerance, but these were not followed. The lack of proper documentation, assessment, and follow-up after the catheter change directly contributed to the resident's injury and subsequent hospitalization.
Failure to Provide Bed Hold Policy Documentation at Discharge
Penalty
Summary
The facility failed to provide required documentation of the bed hold policy to a resident or the resident's representative at the time of discharge to the hospital. Review of the clinical record for a resident with diagnoses including weakness, Crohn's disease, and dementia showed no evidence that the bed hold policy was given at discharge. There was also no documentation that the policy was sent by email or postal service to the resident's representative if needed. Facility policy required that residents or their designated representatives be informed of the bed hold policy in writing at admission, at the time of transfer to a hospital (unless an emergency), or at the time of therapeutic leave exceeding 24 hours. Written notification at the time of transfer was to include the Notice of Transfer and Discharge and a copy of the bed hold policy. In the event of emergency hospitalization, written notice was to be provided within 24 hours. The clinical record lacked documentation that these requirements were met for the resident in question.
Failure to Follow Physician Orders for Peritoneal Dialysis
Penalty
Summary
The facility failed to follow physician's orders for peritoneal dialysis for a resident with multiple diagnoses, including end stage renal disease and dependence on renal dialysis. The orders required staff to take vital signs before and after dialysis, use the resident's morning weight and systolic blood pressure to determine dialysis dose, and to call the dialysis clinic for further instructions if the resident's weight exceeded 216 pounds. Additionally, specific instructions were provided for the use of different dialysis solution bags based on the resident's systolic blood pressure. However, the facility did not clarify conflicting orders regarding which bags to use when the systolic blood pressure was low, and staff did not consistently follow the orders as written. Review of dialysis treatment logs revealed multiple instances where the prescribed protocol was not followed. On several occasions, when the resident's systolic blood pressure was below the specified threshold, the dialysis solution bags used were based on weight rather than blood pressure, contrary to the physician's orders. There were also instances where the concentration of bags used was not documented, and when the resident's weight exceeded 216 pounds, there was no evidence that staff contacted the dialysis clinic for further instructions. Interviews with staff and the DON confirmed that the orders were not always followed and that documentation of required communications with the dialysis clinic was lacking.
Failure to Document and Reassess Restraint Use Leads to Resident Injuries
Penalty
Summary
The facility failed to ensure proper consent and documentation for the use of a physical restraint, specifically a merry walker, for a resident with severe cognitive impairment and a history of falls. The resident, who had multiple diagnoses including dementia with agitation and major depressive disorder, was observed using the merry walker, which was considered a restraint as the resident could not exit it independently. The facility did not complete a consent form with the identified medical reason for the restraint at its initiation, nor did it establish a time frame for its continued use or a plan for its reduction and discontinuation. The resident experienced three falls with major injuries while using the merry walker, resulting in emergency room visits and diagnoses of nasal fractures and facial lacerations requiring sutures. Despite these incidents, there was no documentation in the medical record showing that the facility reassessed the appropriateness of the merry walker after each fall. The facility's policy required that restraints be used only when all other means of keeping a resident safe had been exhausted, and that the use of restraints be carefully monitored to protect resident rights and safety. However, the facility did not adhere to these guidelines, as evidenced by the lack of a written consent and the absence of a documented plan to ensure the restraint was the least restrictive alternative. Interviews with staff and the resident's daughter revealed that the facility relied on verbal discussions rather than documented consent and assessments. The Director of Nursing and the Assistant Executive Director acknowledged the lack of written consent and the absence of a plan to discontinue the restraint. The facility's failure to properly document and reassess the use of the merry walker as a restraint contributed to the resident's repeated falls and injuries, highlighting a significant deficiency in the facility's adherence to its own restraint use policy.
Failure to Conduct Thorough Investigation of Resident Injury
Penalty
Summary
The facility failed to conduct a thorough investigation following an injury of unknown source for a resident with multiple diagnoses, including Alzheimer's disease, dementia, and reduced mobility. The incident report noted bruising and swelling on the resident's right knee, and an x-ray revealed an acute fracture to the right hip. The facility's investigation suggested that the use of a Maxi lift might have caused a pathological fracture, but there was no documentation of a recent fall. Despite this, the Executive Director could not confirm if the Maxi lift was the cause of the fracture. The facility did not conduct interviews with the night shift staff who worked before the injury was noticed, which was a critical oversight in the investigation process. The facility's policy on fall risk identification and investigation was not followed, as it required all falls and potential risks to be investigated. Additionally, the facility did not provide a policy on investigating injuries by the time of the survey exit, further indicating a lack of thorough investigation into the incident.
Failure to Assist Resident with Meals and Monitor Significant Weight Loss
Penalty
Summary
The facility failed to provide adequate assistance and cueing to a resident, identified as Resident 45, during meal times, as per the resident's care plan. Observations over several days revealed that Resident 45, who was diagnosed with dementia, type 2 diabetes mellitus, osteoarthritis, and cerebral infarction, was not being assisted or encouraged to eat by the staff. The resident was often found sitting at the dining table with his silverware still wrapped in a napkin and his food untouched, while staff attended to other residents. Despite the care plan indicating that the resident required supervision and possibly extensive assistance to eat, these needs were not met. Additionally, the facility failed to assess and reweigh Resident 45 following a significant weight loss. The resident's weight dropped from 133.6 pounds to 126.2 pounds within four days, constituting a 5.54% weight loss. However, there was no documentation of a re-weight or assessment for this significant weight change in the electronic health record. The Registered Dietitian (RD) did not trigger a significant weight loss alert because it had not been 30 days, and the resident was not placed on the Nutrition at Risk (NAR) list. The facility's policies on nutrition and weight loss/gain, as well as nutrition risk, were not adequately followed. These policies require interventions when a resident is identified as being at risk for unplanned weight loss, including physician and family notification, and assessment of potential causes for the change. The Assistant Executive Director acknowledged that the Nutrition at Risk notes were missing from the progress notes and that a re-weight request might have been overlooked.
Inadequate Documentation for Antipsychotic Medication Use
Penalty
Summary
The facility failed to provide adequate documentation to justify the decision to decline a gradual dose reduction (GDR) of an antipsychotic medication for a resident diagnosed with unspecified dementia with psychotic disturbance, psychotic disorder with delusions, severe major depressive disorder, and dementia with anxiety. The resident was prescribed risperidone, an antipsychotic, at a dose of 0.75 mg daily. A pharmacy request for a GDR to 0.5 mg daily was declined by the physician, citing intermittent episodes of delusional thinking that could be distressing. However, the clinical records from February to March 2024 did not document any delusions, behaviors, or distress that would support this rationale. The psychiatric progress note from March 19, 2024, indicated that staff reported the resident continued to experience intermittent delusions, but no evidence of delusional thinking or paranoia was observed during the Nurse Practitioner's visit. The Care Tracker Behavior Monitoring and Interventions report documented several instances of the resident expressing frustration, anger, and agitation, but did not include details on interventions used, the duration of behaviors, or the level of distress experienced by the resident. Additionally, there were no corresponding progress notes in the electronic health record for the dates and times of the behaviors listed in the report. The facility's policy on psychotropic medications emphasizes the need for an interdisciplinary approach to limit their use, ensuring they are only prescribed to residents with appropriate diagnoses and documented behavioral symptoms. The policy also requires documentation of attempts to redirect behaviors with less restrictive interventions. In this case, the facility did not adhere to its policy, as there was insufficient documentation to support the continued use of the antipsychotic medication without attempting a GDR, and the specific behaviors and interventions were not adequately recorded in the resident's medical record.
Improper Food Storage and Labeling Practices
Penalty
Summary
The facility failed to maintain proper food storage and labeling practices in its nutrition refrigerators, leading to unsanitary conditions. During an observation, a lunch bag belonging to an LPN was found in the First Floor Unit nutrition refrigerator, which was designated only for specific items like ensures, pudding, and applesauce. Additionally, an open bottle of salad dressing was found without an open date or label. The LPN indicated confusion about the food storage policy, despite a sign on the refrigerator specifying its intended use. The Director of Nursing confirmed that employee food items should be stored in the employee breakroom refrigerator. Further observations revealed additional deficiencies in food storage practices. A refrigerator at the end of the hall contained unlabeled and undated items, such as a gallon of vanilla ice cream and a bag of frozen pastries, and lacked a thermometer. Similarly, a refrigerator/freezer in the common area had an uncovered Styrofoam container of ice cream without a date or label. Interviews with staff indicated a lack of awareness and adherence to the facility's policies, which required labeling and dating of all food items and daily temperature checks of refrigerators. The Assistant Director of Dining was unaware of the refrigerator's presence on the unit, and there was no log for temperature monitoring.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Frankfort
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clinton House Rehabilitation And Healthcare Center | 1.7 mi | ★★★★★ | 16 | 0 |
| Mulberry Health & Rehabilitation Center | 9.2 mi | ★★★★★ | 0 | 0 |
| Milner Community Health Care | 9.3 mi | ★★★★★ | 6 | 0 |
| Witham Extended Care | 15.1 mi | — | 0 | 0 |
| Homewood Health Campus | 15.3 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.