Cycle 1
Health 2025-07-09 · Fire 2025-07-09
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Abilene, TX
Wesley Court Health Center
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
2617 Antilley Road, Abilene, TX
(325) 437-1184
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
30
Certified beds
Average residents
30
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Lifespace Communities
Operator or chain grouping
Approved since
2006-02-22
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
16 facilities
Chain averages 4 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.72
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.06
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.04
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.82
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.78
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.33
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.71
CMS adjusted RN staffing hours
Adjusted total hours
3.78
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,258
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.25
Composite VBP score used to determine payment impact.
Payment multiplier
0.9859
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.06% · Performance 21.81% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.03
Baseline 7.04% · Performance 6.93% · Measure score 3.03 · Achievement 3.03 · Improvement 0.02
Total nurse turnover
4.36
Baseline 84.61% · Performance 55.56% · Measure score 4.36 · Achievement 1.99 · Improvement 4.36
Adjusted total nurse staffing
4.71
Baseline 4.08 hours · Performance 4.42 hours · Measure score 4.71 · Achievement 4.71 · Improvement 1.50
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.38% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 183 · Observed rate 8.74% · Lower 95% interval 7.24% |
| Discharge to community | 48.99% |
50.57%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 167 · Observed rate 46.11% · Lower 95% interval 41.97% |
| Medicare spending per beneficiary | 1.14 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 97.32% |
95.27%
2 pts better
|
Numerator 109 · Denominator 112 |
| Falls with major injury | 0.89% |
0.77%
0.1 pts worse
|
Numerator 1 · Denominator 112 |
| Discharge self-care score | 70% |
53.69%
16.3 pts better
|
Numerator 42 · Denominator 60 |
| Discharge mobility score | 53.33% |
50.94%
2.4 pts better
|
Numerator 32 · Denominator 60 |
| Pressure ulcers or injuries, new or worsened | 2.68% |
2.29%
0.4 pts worse
|
Numerator 3 · Denominator 112 · Adjusted rate 3.58% |
| Healthcare-associated infections requiring hospitalization | 6.93% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 111 · Observed rate 5.41% · Lower 95% interval 4.2% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 54 |
| Staff flu vaccination coverage | 57.74% |
42%
15.7 pts better
|
Numerator 138 · Denominator 239 |
| Discharge function score | 85% |
56.45%
28.5 pts better
|
Numerator 51 · Denominator 60 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 48 · Denominator 48 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 58 · Denominator 58 |
| Resident COVID-19 vaccinations up to date | 7.14% |
25.2%
18.1 pts worse
|
Numerator 4 · Denominator 56 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.0% |
2.7%
0.7 pts better
|
11.4%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.0% |
| Percentage of long-stay residents who lose too much weight | 7.8% |
3.3%
4.5 pts worse
|
5.4%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.4% |
18.9%
3.5 pts better
|
19.6%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.2% |
10.8%
11.4 pts worse
|
16.7%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.0% |
16.1%
1.9 pts worse
|
14.9%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.1% |
15.0%
16.1 pts worse
|
19.8%
11.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 31.1% |
| Percentage of long-stay residents with pressure ulcers | 7.0% |
4.2%
2.8 pts worse
|
5.1%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
89.7%
7.7 pts better
|
81.7%
15.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.2% · Q2 97.5% · Q3 98.9% · Q4 100.0% · 4Q avg 97.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.8% |
12.0%
2.2 pts better
|
12.0%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.8% · Observed 10.1% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.8% |
88.0%
10.8 pts better
|
79.7%
19.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.0% |
25.9%
1.9 pts better
|
23.9%
0.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.0% · Observed 24.7% · Expected 24.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-05 · Fire 2024-06-05
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-05-04 · Fire 2023-05-04
8 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-07-09
F · Potential for more than minimal harm
2025-07-09
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-07-09
F · Potential for more than minimal harm
2024-06-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-19
F · Potential for more than minimal harm
2024-06-05
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-07-05
F · Potential for more than minimal harm
2024-06-05
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-06-30
D · Potential for more than minimal harm
2024-06-05
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-06-30
D · Potential for more than minimal harm
2024-06-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-06-17
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-09
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-07-23
E · Potential for more than minimal harm
2025-07-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-07-08
D · Potential for more than minimal harm
2025-07-09
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-07-23
D · Potential for more than minimal harm
2025-07-09
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-07-23
D · Potential for more than minimal harm
2025-07-09
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2025-07-23
E · Potential for more than minimal harm
2024-06-05
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-06-05
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-06-05
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-06-05
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-06-05
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-06-17
F · Potential for more than minimal harm
2023-05-04
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-05-31
E · Potential for more than minimal harm
2023-05-04
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-05-31
E · Potential for more than minimal harm
2023-05-04
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-05-31
E · Potential for more than minimal harm
2023-05-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-31
D · Potential for more than minimal harm
2023-05-04
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-05-31
D · Potential for more than minimal harm
2023-03-30
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-04-17
D · Potential for more than minimal harm
2023-03-30
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-04-17
B · Minimal harm
2023-03-30
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-04-17
Penalties and ownership
What sits behind the stars
Ownership
Lifespace Communities Inc
5% Or Greater Direct Ownership Interest · Organization
Gorman, Joseph
Corporate Officer · Individual
Harshfield, Nicholas
Corporate Officer · Individual
Jantzen, Jesse
Corporate Director · Individual
Jantzen, Jesse
Corporate Officer · Individual
Lifespace Communities Inc
Operational/Managerial Control · Organization
Pope, Erin
Corporate Officer · Individual
Rodgers, Cynthia
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Windcrest Health & Rehabilitation
Abilene, TX
4-star overall rating with 4-star inspections with $26,364 in total fines with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Mesa Springs Healthcare Center
Abilene, TX
2-star overall rating with 3-star inspections with $8,190 in total fines with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Wisteria Place
Abilene, TX
3-star overall rating with 3-star inspections with $21,645 in total fines with 6 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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