Cycle 1
Health 2025-06-03 · Fire 2025-06-03
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Frankfort, IN
Wesley Manor Health Center
3-star overall rating with 3-star inspections with $20,826 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1555 N Main St, Frankfort, IN
(765) 659-1811
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
96
Certified beds
Average residents
92
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Bhi Senior Living
Operator or chain grouping
Approved since
1998-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 4 overall / 4 health / 3 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
0.47
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.11
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.45
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.34
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.00
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.38
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
3.32
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,856
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.51
Composite VBP score used to determine payment impact.
Payment multiplier
0.9865
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.21
Baseline 17.65% · Performance 20.87% · Measure score 1.21 · Achievement 1.21 · Improvement 0
Healthcare-associated infections
1.72
Baseline 7.13% · Performance 7.32% · Measure score 1.72 · Achievement 1.72 · Improvement 0
Total nurse turnover
8.13
Performance 30.44% · Measure score 8.13 · Achievement 8.13 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.53
Baseline 3.92 hours · Performance 3.51 hours · Measure score 1.53 · Achievement 1.53 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.18% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 76 · Observed rate 11.84% · Lower 95% interval 7.1% |
| Discharge to community | 52.46% |
50.57%
1.9 pts better
|
No Different than the National Rate · Eligible stays 68 · Observed rate 47.06% · Lower 95% interval 41.22% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 89.74% |
95.27%
5.5 pts worse
|
Numerator 35 · Denominator 39 |
| Falls with major injury | 10.26% |
0.77%
9.5 pts worse
|
Numerator 4 · Denominator 39 |
| Discharge self-care score | 44% |
53.69%
9.7 pts worse
|
Numerator 11 · Denominator 25 |
| Discharge mobility score | 48% |
50.94%
2.9 pts worse
|
Numerator 12 · Denominator 25 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 39 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.32% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 8.33% · Lower 95% interval 3.91% |
| Staff COVID-19 vaccination coverage | 8.51% |
8.2%
0.3 pts better
|
Numerator 16 · Denominator 188 |
| Staff flu vaccination coverage | 6.77% |
42%
35.2 pts worse
|
Numerator 13 · Denominator 192 |
| Discharge function score | 52% |
56.45%
4.5 pts worse
|
Numerator 13 · Denominator 25 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 40.91% |
25.2%
15.7 pts better
|
Numerator 9 · Denominator 22 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.6
About the same
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.4 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.1 |
1.5
1.6 pts worse
|
1.8
1.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 2.8 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.6%
6.4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.8% |
95.4%
3.4 pts better
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.1% |
3.8%
1.3 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 7.7% · Q3 2.7% · Q4 4.9% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 28.1% |
24.6%
3.5 pts worse
|
11.4%
16.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.7% · Q2 34.7% · Q3 29.2% · Q4 25.3% · 4Q avg 28.1% |
| Percentage of long-stay residents who lose too much weight | 6.5% |
5.6%
0.9 pts worse
|
5.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 4.5% · Q3 3.0% · Q4 9.3% · 4Q avg 6.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.1% |
23.5%
9.6 pts worse
|
19.6%
13.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.7% · Q2 36.8% · Q3 30.0% · Q4 26.3% · 4Q avg 33.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.6% |
14.8%
6.2 pts better
|
16.7%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 10.5% · Q3 5.0% · Q4 3.0% · 4Q avg 8.6% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 30.7% |
13.3%
17.4 pts worse
|
16.3%
14.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.5% · Q2 31.5% · Q3 22.1% · Q4 28.5% · 4Q avg 30.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 37.8% |
11.7%
26.1 pts worse
|
14.9%
22.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.4% · Q2 41.5% · Q3 36.4% · Q4 37.1% · 4Q avg 37.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.8% |
0.4%
1.4 pts worse
|
1.0%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 2.4% · Q4 2.2% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.2% |
1.2%
2 pts worse
|
1.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 3.9% · Q3 1.4% · Q4 1.2% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 34.9% |
24.2%
10.7 pts worse
|
19.8%
15.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.8% · Q2 39.8% · Q3 31.6% · Q4 32.1% · 4Q avg 34.9% |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
4.1%
1.8 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.7% · Q3 3.7% · Q4 1.2% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.6% |
81.6%
16 pts better
|
81.7%
15.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.3% · Q2 95.3% · Q3 100.0% · Q4 97.7% · 4Q avg 97.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.9% |
10.5%
6.4 pts worse
|
12.0%
4.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.9% · Observed 17.0% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.3%
0.1 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 4.5% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.6% |
79.0%
9.6 pts better
|
79.7%
8.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.5% |
22.4%
5.9 pts better
|
23.9%
7.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.5% · Observed 17.0% · Expected 24.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-18 · Fire 2024-06-18
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-04-04 · Fire 2023-04-04
6 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-03
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-07-16
E · Potential for more than minimal harm
2025-06-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-07-16
E · Potential for more than minimal harm
2025-06-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-07-16
E · Potential for more than minimal harm
2024-06-18
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-07-17
F · Potential for more than minimal harm
2023-04-04
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-08
E · Potential for more than minimal harm
2023-04-04
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-05-08
E · Potential for more than minimal harm
2023-04-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-08
Inspection history
Recent health citations
G · Actual harm
2025-12-11
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2026-01-01
D · Potential for more than minimal harm
2025-06-03
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-05-21
D · Potential for more than minimal harm
2025-06-03
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-06-18
G · Actual harm
2024-06-18
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-06-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-06-18
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-06-18
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 2024-07-18
D · Potential for more than minimal harm
2024-06-18
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 2024-07-18
G · Actual harm
2023-09-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-20
F · Potential for more than minimal harm
2023-04-04
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 2023-05-17
D · Potential for more than minimal harm
2023-04-04
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-05-17
D · Potential for more than minimal harm
2023-04-04
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-05-17
D · Potential for more than minimal harm
2023-04-04
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-05-17
D · Potential for more than minimal harm
2023-04-04
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-05-17
Penalties and ownership
What sits behind the stars
$20,826
2024-06-18
Fine
Fine · fine $20,826
Fine
Ownership
Woodlawn Hospital
5% Or Greater Direct Ownership Interest · Organization
Fisher, Alan
Operational/Managerial Control · Individual
Fisher, Alan
Corporate Officer · Individual
Mustaklem, Marwan
Operational/Managerial Control · Individual
Waymire, Gary
Operational/Managerial Control · Individual
Wesley Manor Inc.
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Clinton House Rehabilitation And Healthcare Center
Frankfort, IN
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Mulberry Health & Rehabilitation Center
Mulberry, IN
4-star overall rating with 5-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Milner Community Health Care
Rossville, IN
3-star overall rating with 4-star inspections with 1 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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