Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Court Health Center during CMS and state inspections, most recent first.
A resident reported that food was frequently overcooked, dry, and tough, and a test tray confirmed meats were served at unappetizing temperatures and textures. The DM acknowledged responsibility and cited the use of plastic plates during dishwasher installation as a factor, while the ADMN identified improper staff training and lack of oversight as contributing causes.
Staff did not adhere to hand hygiene and glove-changing protocols during meal service, with a dietary aide and the dietary manager both handling and serving food without washing hands or changing gloves after potential contamination. All residents who ate from the kitchen were potentially affected by these lapses, despite staff being trained on infection control and facility policies requiring proper hand hygiene.
Two residents were discharged without completed discharge summaries in their EMRs, despite facility policy and staff expectations that the discharging nurse would complete this documentation. Both residents had their discharges noted in progress notes, but the required summaries recapping their stays and final status were missing.
A newly admitted resident with a colostomy and Type 2 Diabetes Mellitus did not have these conditions addressed in the baseline care plan within 48 hours of admission. The care plan lacked necessary instructions for colostomy and diabetes care, despite these needs being documented in the resident's records and physician orders. Staff interviews confirmed the omission and acknowledged that the baseline care plan should have included these diagnoses and care needs.
A resident receiving hospice care did not have the required hospice documentation, including the certificate of terminal illness and hospice election form, maintained in her records. The DON confirmed these documents should have been available in the hospice binder, but they were missing, possibly due to a recent change in social worker staff. The facility's policy requires these forms to be obtained and maintained for all hospice patients.
The facility failed to complete the social services section of baseline care plans within 48 hours of admission for four residents, potentially risking unmet care needs. Interviews revealed that the absence of a social worker contributed to this deficiency, as staff were unable to complete the necessary sections. The facility's policy mandates that baseline care plans include social services to ensure effective, person-centered care.
A facility failed to address pharmacist recommendations for a resident's psychotropic medications, including hydroxyzine and risperidone. The resident's care plan required monitoring for side effects and dosage reduction consultation, but recommendations regarding PRN use and diagnosis support were not timely addressed. The DON acknowledged the delay and potential for unnecessary medication use.
A facility failed to limit the use of PRN hydroxyzine for a resident with anxiety, as required by policy. The resident received the medication daily without a stop date, and repeated requests for clarification on the duration of use were not addressed. The DON acknowledged the oversight, which could result in unnecessary medication use.
The facility failed to maintain a QAPI committee with required members and quarterly meetings. Documentation for meetings in July 2023 and January 2024 was missing, and meetings in October 2023 and February 2024 lacked required members like the DON and Medical Director. Interviews revealed issues with record-keeping, as previous meeting records were misplaced. This deficiency could risk residents' quality of care.
The facility failed to provide the required annual dementia training to two CNAs, placing residents at risk due to untrained staff. Personnel files showed no evidence of the necessary training, and the administrator was unaware of the specific policies regarding dementia training.
Failure to Serve Palatable and Properly Heated Food
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature during a lunch meal. Observation and interview revealed that a resident reported repeated issues with the food, specifically that the meat was often overcooked, dry, and tough. During a test tray evaluation, the chicken breast was found to be thin and dry with a temperature of 111°F, and the pork loin was tough with a temperature of 104°F. The Dietary Manager (DM) confirmed that the meats were not hot or appealing and acknowledged responsibility for ensuring food was properly cooked and served at the correct temperature. The DM attributed the lack of warm food to the use of plastic plates while a new dishwasher was being installed but could not explain the overcooking of the meat. Further interviews with the Administrator (ADMN) confirmed expectations that food should be cooked correctly and served at an appetizing temperature. The ADMN stated that both he and the DM were responsible for monitoring staff and food quality, and that improper staff training and lack of oversight contributed to the failure. Facility policy required that food be inspected for palatability, attractiveness, and safe temperature, but these standards were not met during the observed meal service.
Failure to Follow Hand Hygiene and Glove Use During Food Service
Penalty
Summary
Staff failed to follow proper hand hygiene and glove use protocols during food service in the facility's kitchen. Observations showed that a dietary aide entered the dining room, donned gloves without washing her hands, and assisted with plating and serving food to residents. She repeatedly left the dining room to go to the main kitchen and returned without changing gloves or performing hand hygiene, continuing to serve food. The dietary manager also participated in meal service without washing his hands, including after touching a resident and using the microwave, and did not change gloves during the process. Interviews with the dietary manager, dietary aide, and administrator confirmed that all had been trained on hand hygiene and infection control, and acknowledged the expectation for staff to wash hands before handling food and after any potential contamination. The facility's policy required handwashing before contact with food surfaces and as often as necessary to prevent cross contamination. The administrator verified that all residents consumed food from the kitchen and could be affected by these lapses.
Failure to Complete Discharge Summaries for Two Residents
Penalty
Summary
The facility failed to ensure the completion of discharge summaries, including a recapitulation of the resident's stay and final status at discharge, for two residents who were reviewed for discharge documentation. For both residents, the electronic medical record (EMR) lacked evidence of a completed discharge summary following their discharge to the community. One resident, a female with diagnoses of pneumonia, hypertension, and dementia, was discharged back to assisted living, while the other, a female with cerebral infarction, hypertension, and kidney disease, was discharged home accompanied by a family member. In both cases, the progress notes documented the discharge event, but no formal discharge summary was present in the EMR. Interviews with facility staff revealed that the nurse responsible for discharging the resident was expected to complete the discharge summary and enter it into the EMR. The MDS coordinator and the DON both confirmed that discharge summaries were missing for the two residents and acknowledged that the summaries should have been completed at the time of discharge. The facility's policy required a discharge summary to be developed when a resident's discharge was anticipated, but this was not followed in these instances.
Failure to Develop Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident who had a colostomy and a diagnosis of Type 2 Diabetes Mellitus with hyperglycemia. The baseline care plan did not include instructions or interventions related to the resident's colostomy care or diabetes management, despite these being documented in the resident's medical records and physician orders. The omission was identified through record review, observation, and interviews, which confirmed that the baseline care plan lacked necessary information to address the resident's specific health needs. Interviews with the DON and MDS Coordinator revealed that the charge nurse responsible for admitting the resident did not include the required diagnoses and care instructions in the baseline care plan. Both staff members acknowledged that the baseline care plan should have addressed the resident's medical devices and diagnoses, and that the failure to do so meant staff did not have the information needed to provide appropriate care. The facility's policy required a baseline care plan to be developed within 48 hours of admission, including all relevant diagnoses and care needs, but this was not followed in this instance.
Failure to Maintain Required Hospice Documentation and Coordinate Care
Penalty
Summary
The facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services. Specifically, the facility did not maintain the required hospice forms and documentation, including the certificate of terminal illness and the hospice election form, for a female resident with diagnoses of dementia, kidney disease, and high blood pressure. The resident was admitted to the facility and was on hospice care, as indicated in her medical records and care plan. However, a review of her clinical records revealed that the necessary hospice documentation was missing. During an interview, the DON confirmed that the certificate of terminal illness and hospice election form should have been present in the hospice binder at the nurses' station and available at all times. The DON was unsure why the documents were missing and stated that the social worker was typically responsible for communication with hospice and ensuring the required documents were in place. The facility had recently hired a new social worker, which was suggested as a possible reason for the oversight. The facility's policy requires obtaining the hospice election form and physician certification of terminal illness for each resident receiving hospice services.
Incomplete Baseline Care Plans for Newly Admitted Residents
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for four residents, which included necessary instructions for effective and person-centered care. The deficiency was identified through interviews and record reviews, revealing that the social services section of the baseline care plan was not completed for any of the four residents reviewed. This omission could potentially place newly admitted residents at risk of not receiving necessary care and services or having important care needs identified. Resident #85, a male with multiple diagnoses including spinal fracture, muscle weakness, and cognitive impairment, was admitted without a completed social services section in his baseline care plan. Similarly, Resident #87, a female with conditions such as cauda equina injury and hypothyroidism, also lacked a completed social services section in her baseline care plan. Resident #137, a male with a right leg fracture and cognitive impairment, and Resident #185, a female with atrial fibrillation and acute respiratory failure, were also admitted without the social services section completed in their baseline care plans. Interviews with facility staff, including an LVN, the DON, the interim administrator, and the MDS coordinator, revealed that the absence of a social worker at the time may have contributed to the incomplete sections. The staff acknowledged that the social services section was crucial for assessing psychosocial needs and that its omission could lead to unmet needs. The facility's policy requires that the baseline care plan include social services, among other elements, to ensure effective and person-centered care until a comprehensive care plan is developed.
Failure to Address Pharmacist Recommendations for Psychotropic Medications
Penalty
Summary
The facility failed to address drug regimen irregularities reported by the Pharmacist Consultant for a resident who was reviewed for unnecessary medications, psychotropic medications, and medication regimen review. The resident, a female with diagnoses including anxiety, prediabetes, and a fracture of the right lower leg, was admitted to the facility and had a BIMS score indicating no cognitive impairment. The resident's care plan included the use of anti-anxiety medication (hydroxyzine) and psychotropic medication (risperidone) with specific goals and interventions outlined, such as monitoring for side effects and consulting with pharmacy and medical staff for dosage reduction. The Pharmacist Consultant made recommendations in April and May 2024 regarding the resident's medication regimen, specifically questioning the duration of PRN hydroxyzine use and the lack of an allowable diagnosis for the use of risperidone. Despite these recommendations, the facility did not address them in a timely manner. The resident's electronic physician orders did not include a stop date for hydroxyzine or evidence of monitoring for antipsychotic side effects until June 2024. The facility's policy on psychotropic medication use requires that such medications are not prescribed or given on a PRN basis unless necessary for a diagnosed condition, with PRN orders limited to 14 days unless extended by a physician. Interviews with the Director of Nursing (DON) revealed that the responsibility for monitoring and addressing pharmacy recommendations was shared with the Assistant Director of Nursing (ADON). The DON acknowledged that recommendations should be addressed within 72 hours and that repeated recommendations indicate a failure to address them. The delay in addressing the recommendations was attributed to the Medical Director not addressing psychotropic medications promptly and the psych doctor responding less timely. The DON admitted that the recommendations could have been addressed without physician notification and recognized the potential for the resident to receive unnecessary medications.
Failure to Limit PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident with a PRN order for the psychotropic drug hydroxyzine had a stop date, which is required to limit the use of such medications to 14 days unless otherwise specified by a physician. This oversight was identified during a review of the resident's electronic face sheet and medication administration records. The resident, a female with a history of anxiety, prediabetes, and a leg fracture, was admitted to the facility and had been receiving hydroxyzine daily without a specified stop date. The facility's care plan for the resident included monitoring for side effects and effectiveness of the anti-anxiety medication every shift, but the medication regimen reviews repeatedly requested clarification on the duration of the PRN hydroxyzine use. Despite these requests, there was no documented rationale from the physician for the continued provision of the medication, nor was there any indication that the medication should be scheduled rather than PRN. Interviews with the Director of Nursing (DON) revealed that the responsibility for addressing pharmacy recommendations was shared with the Assistant Director of Nursing (ADON). The DON acknowledged that the recommendations should have been addressed within 72 hours and that the delay in addressing them could have resulted in the resident receiving unnecessary medications. The facility's policy on psychotropic medication use clearly states that PRN orders for such medications are limited to 14 days unless extended by a physician with documented rationale, which was not adhered to in this case.
Failure to Maintain Proper QAPI Committee Meetings
Penalty
Summary
The facility failed to maintain an ongoing Quality Assurance & Performance Improvement (QAPI) committee that included the required members and met at least quarterly. Specifically, the facility did not hold QAPI meetings with the necessary members present for two of the four required quarterly meetings. The facility was unable to provide sign-in sheets for the meetings in July 2023 and January 2024, and the documentation for the meetings held in October 2023 and February 2024 did not include all required members, such as the Director of Nursing (DON) and the Medical Director or their designee. Interviews with the Executive Director (ED) and the DON revealed that the facility had issues with maintaining proper documentation of the QAPI meetings. The ED stated that the previous Administrator had been responsible for keeping track of the meetings on paper, and the records were moved into storage boxes, making them difficult to locate. Both the ED and the DON verbally confirmed that the meetings had been conducted, but they were unable to provide the necessary documentation to prove it. The lack of documentation and the absence of required members at the meetings could potentially place residents at risk for reduced quality of care and life.
Deficiency in Dementia Training for CNAs
Penalty
Summary
The facility failed to ensure that two certified nurse aides (CNA-B and CNA-C) received the required minimum 1-hour annual in-service training for dementia care. This deficiency was identified through interviews and record reviews, which revealed that the personnel files for CNA-B and CNA-C, who were hired in early 2024, lacked evidence of the necessary dementia training. The absence of this training placed residents at risk for unmet needs due to the staff's lack of preparation in handling dementia-related situations. During an interview, the administrator (ADMN) acknowledged that the Human Resources (HR) and the Director of Nursing (DON) were responsible for monitoring staff training. However, the ADMN was unaware of the specific policies regarding dementia training and did not perceive any negative impact on residents due to this oversight. The facility's policy, revised in October 2023, mandates that all staff participate in orientation and annual in-service training, including dementia management and resident abuse prevention, to ensure competency in enhancing residents' quality of life and care.
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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 Abilene
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Windcrest Health & Rehabilitation | 0.5 mi | ★★★★★ | 11 | 0 |
| Mesa Springs Healthcare Center | 1.7 mi | ★★★★★ | 15 | 0 |
| Wisteria Place | 2.8 mi | ★★★★★ | 5 | 1 |
| Willowcreek Rehab And Nursing | 5.3 mi | ★★★★★ | 9 | 0 |
| Brightpointe At Lytle Lake | 5.4 mi | ★★★★★ | 10 | 2 |
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