Mesa Springs Healthcare Center
7171 Buffalo Gap Rd, Abilene, TX 79606 · For profit - Corporation · 89 certified beds · (325) 692-8080 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,190 in federal fines (most recent 2023-10-12)
- its payroll-based staffing rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 14.2% | 15.8% | 15.4% | typical |
| Long-stay residents who lose too much weight | 3.8% | 3.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.3% | 0.9% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.5% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 2.4% | 2.4% | 6.5% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.3% | 3.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 28.0% | 14.0% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 10.4% | 18.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 96.5% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.1% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 18.2% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.3% | 9.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.4% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 94.2% | 88.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 28.7% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 11.1% | 12.3% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.61 | 2.17 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 2.47 | 2.06 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
48.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 86 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 73.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 65 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.42 therapist hours per resident per day in 2026Q1 — more than 71% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 48.6%CMS range 36.5–60.6 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.1%CMS range 8.1–15.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 73.8% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 55.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 58.5% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 94.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 98.2% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.7%CMS range 5.6–13.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.00 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 89 beds and averages 68.3 residents a day — about 77% occupied, or roughly 21 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.45 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.48 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.00 hrs/resident/day on weekends vs 3.63 on weekdays — 17% thinner on weekends. RN hours go from 0.51 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
33 citations, most serious first. The 11 most serious are shown; the remaining 22 are one tap away and print in full.
- Actual harm · Gcited before2023-10-12 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to ensure the comprehensive care plan described the services and interventions to be used to attain and maintain the resident's practicable physical, mental, and psychosocial well-being for 1 (Resident #6) of 3 residents reviewed for care plans. The care plan for Resident #6 did not adequately address his interventions to describe how to meet his needs when transferring resulting in a fracture to right arm. This deficient practice placed residents at risk of not having care needs met, which could cause a decline in physical and psychosocial health and serious injury. Findings include: Record review of Resident #6's Face Sheet, dated 10/04/2023, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #6's diagnoses included Unspecified displaced fracture (pieces of the bone moved so much that a gap formed around the fracture) of the surgical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-15 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to implement their written policies and procedures regarding allegations of abuse/neglect for one (Resident #1) of seven residents reviewed for abuse/neglect. The facility did not report an incident of neglect to the state agency within the given time frame. These failures could place all residents that access the facility van. The findings included:Record review of Resident #1's Face Sheet, dated April 14, 2026, revealed a [AGE] year-old female with the latest admission date of 08/24/2025. Her diagnoses included Hemiplegia, unspecified affecting right dominant side (a type of paralysis that affects one side of the body, often resulting from brain damage due to conditions such as a stroke or injury); and ataxic gate (an unsteady, irregular walking pattern caused by cerebellar dysfunction, leading to poor coordination and balance); and cognitive communication deficit (difficulty in communications that arise from impaired cognitive functions). Record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2026-03-19 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS, for 1 of 1 (FY Quarter 4 2025) reviewed for Staffing Data Report. The facility failed to submit staffing information to CMS for FY Quarter 4 2025 (October 1- December 31). The facility's failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. The findings included: Review of the facility's Staffing Data Report for FY Quarter 4 2025 (October 1- December 31) reflected the facility triggered for Failed to Submit Data for the Quarter. Review of the facility's PBJ nurse staffing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-03-19 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 3 (Resident #19, Resident#24 and Resident#31) of 12 residents reviewed for quality of care.The facility failed to ensure Resident #19 and #24's nasal canula was properly stored while oxygen was not in use on 03/17/2026.The facility failed to ensure Resident #31's nebulizer mask was properly stored while not in use on 03/17/2026. These failures could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health.The findings include:1. Record review of Resident #19's admission Record dated 03/18/2026 revealed a [AGE] year-old female admitted on [DATE].Record review of Resident #19's History and Physical dated 11/25/2025 revealed resident had a diagnosis of hypoxic respiratory failure (a life threating condition where the lungs cannot adequately transfer…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-03-19 · tag F0700 — patternTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to review the risks and benefits of bed rails with the resident or a resident representative and obtain informed consent prior to installation for 3 of 5 residents (Resident #2, Resident #3, and Resident #6) reviewed for bed rail consents. 1. The facility failed to obtain informed consent, or maintain evidence that, Resident #2 and Resident #3 or their representative had been provided with sufficient information so that they could make an informed decision prior to installing bed rails.2. The facility failed to obtain informed consent from Resident #6 when bed rails were installed on his bed. Informed consent was obtained 17 days after bed rail safety evaluation was performed and 23 days after physician order was obtained. This failure could place residents at risk of not being able to make an informed decision due to not having sufficient information on the risks of bed rail usage.Findings included:1. Record review of Resident #2's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-03-19 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure each resident received, and the facility provided food and drink that was palatable, attractive, and at safe and appetizing temperatures for reviewed food and nutrition services.The facility failed to adhere to their policy for acceptable serving temperatures on 03/17/26.This failure could place residents at risk of food-borne illnesses, decreased appetite, and overall meal dissatisfaction.Findings included:In an observation on 03/17/26 at 12:10 PM, the Meal Cart for the 100-hall left the kitchen into the 100-hall. The last tray was observed to be served by staff into their room at 12:23 PM. All sample trays were tested for temperature and all meal entrees were under the serving temperature per facility policy. All trays were in transported in a meal cart with the plate covering on. On 03/17/26 at 12:25 PM, the Food Sample Trays tested at the following: Mechanical diet- 114 F Steak Fritters, 118 F [NAME] Beans, and 111 F Red Potatoes; Regular diet- 130 F Steak Fritters, 115 F [NAME] Beans, and 117 F…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-03-19 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen in the facility.1.The facility failed to date a tray of covered cups of milk and fruit cups on 03/17/26.2. The facility failed to keep 2 boxes of Vanilla pudding cups off the floor in the walk-in pantry on 03/17/26.3. The facility failed to ensure the steam table was clean and free from food particles on 03/17/26.4. The facility failed to ensure cookware was properly rinsed and sanitized in adherence to professional standards for food service safety on 03/17/26.These failures could place residents at risk of food-borne illnesses.Findings include:During the brief initial kitchen interview on 03/17/26 at 8:55 AM, the following observations were made: a serving tray with multiple cups of milk covered with plastic wrapping, 3 small bowls of served fruit covered with plastic wrapping, and a cup of gelatin, located in the walk-in refrigerator, was not dated; 2 boxes of Vanilla puddings on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-19 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 16 residents (Resident #2 and Resident #3) reviewed for care plans. The facility failed to ensure Resident #2, and Resident #3 had a care plan in place for bed rails. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.Findings included:1. Record review of Resident #2's electronic face sheet, dated 03/18/2026, reflected an [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnosis including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (left sided weakness or immobility following a stroke), and muscle weakness, Record review of Resident #2's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-06 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews, the facility failed to ensure residents had the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal for 1 of 5 residents (Resident #312) reviewed for grievances. The facility failed to ensure a grievance was completed for Resident #312's complaint of LVN A. This failure could place residents at risk for not having their grievances resolved. The findings included: Record review of Resident #312's electronic face sheet indicated a [AGE] year-old female, who was initially admitted to the facility on [DATE] with a current admission date of 05/31/25. Resident #312's medical diagnoses included dementia, asthma, weakness, chronic kidney disease, stage 4 severe, pressure ulcer on left buttock, difficulty swallowing, type 2 diabetes mellitus, Parkinson's disease, heart failure, anemia, high blood cholesterol, high blood pressure, gout, cognitive communication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-06 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and misappropriation for 1 of 5 residents (Resident #312) reviewed for developing and implementing neglect policies. The facility failed to follow its policy to investigate and report to the Texas Health and Human Services Commission (HHSC) when Resident #312's family member alleged that LVN A neglected Resident #312. This failure could place residents at risk of not having allegations thoroughly investigated per policy. Findings included: Record review of Resident #312's electronic face sheet indicated a [AGE] year-old female, who was initially admitted to the facility on [DATE] with a current admission date of 05/31/25. Resident #312's medical diagnoses included dementia, asthma, weakness, chronic kidney disease, stage 4 severe, pressure ulcer on left buttock, difficulty swallowing, type 2 diabetes mellitus, Parkinson's disease, heart failure, anemia, high blood…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-16 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate administering of all drugs and biologicals to meet the needs of the residents for 1 of 1 medication room and 1 of 3 (treatment cart) medication carts reviewed for drugs and biologicals. 1. The facility failed to ensure 1 vancomycin IV bag (antibiotic medication in bag for IV) had been removed from the medication room when it had expired on December 2024. 2. The facility failed to ensure 6 boxes of lancets (needles used to obtain small blood samples) were removed from the medication room when they had expired on or after 08/27/2020. 3. The facility failed to ensure 12 IV start kits (used to start IVs) were removed from the medication room when they had expired on 12/10/2024. 4. The facility failed to ensure 8 packages of lubricating jelly (used for lubrication) were removed from the medication room when they had expired on 12/02/2024. 5. The facility failed to ensure 1 tube of Anasept gel (topical solution that fights bacteria and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 22 citations
- Potential for harm · E2025-01-16 · tag F0770 — failed to provide lab services — patternProvide timely, quality laboratory services/tests to meet the needs of residents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review the facility failed to ensure the quality of laboratory services in the facility for 1 of 1 medication room reviewed for drugs and biologicals. The facility failed to ensure 2 boxes of COVID testing kits (used for COVID testing) were removed from the medication room when they had expired on 12/15/2023. The facility failed to ensure 1 box and 4 packages of influenza A & B Tests (used for Flu testing) were removed from the medication room when they had expired on 11/30/2024. These failures could place residents at risk of inaccurate testing results. Findings included: During an observation of the medication room on 01/15/2025 at 7:37 a.m. revealed: 1. 2 boxes of expired COVID testing kits expired on 12/15/2023. 2. 1 box and 4 packages of expired influenza A & B testing kits expired on 11/30/2024. During an interview on 01/15/2025 at 8:42 a.m., LVN F stated COVID and influenza tests should be disposed of after they were expired. She stated she did not know why expired test kits were in the medication room. LVN F stated COVID and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-01-16 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitization. The facility failed to ensure foods in Refrigerator #1, Refrigerator #2, and the freezer were not sealed and/or labeled properly. The facility failed to ensure food that left the kitchen was covered. This failure could place residents that eat out of the kitchen at risk for contamination and food borne illnesses. Findings included: During an observation on 01/14/2025 at 10:15 AM of facility kitchen revealed the following: Refrigerator #1: 1 bin of Celery was unlabeled and with no in date and was open to air, and 1 box of Muffins was unsealed and open to air. Refrigerator #2: 1 box of sausage was unsealed and open to air, in refrigerator. Freezer: 1 box of Cannoli was unsealed and open to air. During an observation and interview on 01/15/2025 at 9:07 AM with the DM observed in the refrigerators the open to air product (cannoli's, celery…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-16 · tag F0813 — patternHave a policy regarding use and storage of foods brought to residents by family and other visitors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed implement its policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for 3 (Resident #23, Resident #36, and Resident #65) of 18 residents reviewed for food and nutrition services. 1. The facility failed to ensure that Resident #36's personal refrigerator did not have expired goods stored and failed to log refrigerator's temperature after 01/01/2025. 2. The facility failed to ensure that Resident #65's personal refrigerator did not have expired goods stored and failed to have a thermometer inside to check temperature. 3. The facility failed to ensure that Resident #23's personal refrigerator had a thermometer inside to check temperature and failed to keep temperature log during the month of January 2025. These failures could place residents at risk for foodborne illnesses. The findings were: 1.During an observation and interview on 01/14/2025…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-01-16 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (CMA J and CMA K) of 6 staff observed for infection control practices. The facility failed to ensure CMA J wore the required PPE in a Resident #17's room while providing medication and eye drops for Resident #17. The facility failed to ensure CMA K sanitized face shield per infection control protocols and procedures. These failures place residents at risk for cross contamination and spreading of infections while in facility. Finding included: Record review of facility provided document for Covid testing of residents revealed: Resident #12 tested positive for COVID on 1/11/2025; Resident #17 tested positive for COVID on 01/10/2025; and Resident #41 tested positive of Covid on 1/11/2025. During an observation on 1/14/2025 between 10:30 AM and 10:40 AM Resident #17 and Resident # 12's had signs on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-16 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to ensure residents had the right to voice grievances to the facility with respect to care and treatment which had been furnished as well as that which had not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay for 1 of 18 residents (Resident #171) reviewed for grievances. The facility failed to investigate and respond to a grievance made by Resident #171's representative who made a grievance to RN A. This failure could place residents and their representatives at risk of not having their grievances heard and or resolved. The findings included: Record review of Resident #171's electronic face sheet dated 01/15/2025 revealed she was a female admitted to the facility on [DATE] and most recently on 07/14/2023 with diagnoses to include: unspecified dementia, muscle weakness, anxiety disorder, and major depressive disorder. Record review of Resident #171's quarterly MDS dated [DATE] revealed no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-16 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to refer residents with newly evident or possible serious mental illness or a related condition for PASSR evaluation for 2 of 18 residents (Resident #27, and Resident #29) reviewed for PASRR. The facility failed to refer Resident #27 & Resident #29 for a PASSR evaluation after diagnoses reflected serious mental disorders. This failure placed residents at risk of not receiving or benefiting from specialized therapy and equipment services they may require. Findings included: Resident #27 Record review of Resident #27's electronic face sheet dated 01/16/2025 revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #27 had a diagnosis of major depressive disorder with onset date of 03/08/2024. Resident #27 had a diagnosis of post-traumatic stress disorder with onset date on 03/08/2024. Record review of Resident #27's quarterly MDS dated [DATE] revealed Resident #27 had a BIMS score of 15 meaning cognition was intact. Further review…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to assistance devises to prevent accidents for 1 of 29 residents (Resident #12) whose records were reviewed for quality of care. The facility failed to ensure that Resident #12's wheelchair was placed at Resident #12's bedside as care planned to prevent falls. This failure could place residents at risk of being injured. Findings included: Review of Resident #12's electronic face sheet revealed a [AGE] year-old male admitted on [DATE] with an original admission date of 07/11/2017 with the following diagnosis Alzheimer's disease, history of falls, chronic kidney disease, and lack of coordination. Record review of Resident #12's Quarterly MDS dated [DATE] revealed Section C- Cognitive Patterns a BIMS of 6 (meaning severe cognitive impairment); Section J-Health Conditions revealed that Resident #12 had a history of falls with injury. Record review of Resident #12's Care Plan dated 12/09/2024 revealed an intervention of wheelchair close to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-16 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and/or the residents' goals and preferences, for 1 of 29 (Resident #12) reviewed for respiratory care. The facility failed to ensure that Resident #12's oxygen tubing had been changed weekly per physician order. This failure places residents that use oxygen at risk of respiratory complications and/or possible respiratory infections. Findings included: Review of Resident #12's electronic face sheet revealed a [AGE] year-old male admitted on [DATE] with an original admission date of 07/11/2017 with the following diagnosis Alzheimer's disease, history of falls, chronic kidney disease, heart disease, and COVID positive. Record review of Resident #12's Quarterly MDS dated [DATE] revealed Section C- Cognitive Patterns a BIMS of 6 (meaning severe cognitive impairment);…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-16 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments and to permit only authorized personnel to have access to 1 (treatment cart) of 5 medication carts reviewed for security. The facility failed to ensure treatment cart with prescription medications and biologicals were not left unlocked, unsecured, and unattended. These failures could place residents at risk of misappropriation of medications, drug diversions, or accidental ingestion. The findings included: During an observation on 01/16/2025 at 12:10 p.m. the treatment cart was sitting at the nurses' station with no nursing staff present ; residents were observed in area of the treatment cart. Items in treatment cart included: Insulin pens (insulin filled containers in pen form), Insulin needles (needles to give insulin), lancets (device used to obtain blood sample for finger stick blood sugar), albuterol (medication in inhaler used for shortness of breath), Breztri (medication in inhaler used for shortness of breath), Trelegy (medication in inhaler used…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-21 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 2 of 3 (Residents #1 and Resident #2) residents observed for dignity. CNA A and CNA B failed to provide Resident #1 with full privacy while providing incontinent care on 10/29/24. Facility failed to provide Resident #2 with a privacy curtain installed in her room on 11/19/2024. These failures could place residents at risk of not being treated with dignity and respect. The findings included: Record review of Resident'#1's admission Record, dated 11/21/24, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia, anemia, repeated falls, and lack of coordination. Record review of a Significant Change MDS assessment dated [DATE] indicated Resident #1 had a BIMS score of 99 which indicated Resident #1 could not complete BIMS examination. Record review of a comprehensive care plan dated 11/19/24 indicated Resident #1 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-25 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to thoroughly investigate allegations of abuse and neglect for 1 (Resident #1) of 7 residents reviewed. The facility did not have evidence that a thorough investigation was completed for Resident #1 allegation of being verbally abused. This failure could place residents at risk of incidents not being thoroughly investigated and subject to further abuse. The findings included: 1.Record review of Resident'#1's admission Record, dated 6/25/2024, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included cerebral infarction due to embolism of right cerebellar artery (a cerebrovascular event involving the posterior cranial fossa, specifically targeting the cerebellum), type 2 diabetes, and hypertension. Record review of Resident #1's State Optional MDS, dated [DATE], revealed the resident had a BIMS score of 10, which indicated the resident was mildly cognitively impaired for daily decision-making…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-25 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed review and revise the comprehensive plan of care to meet a resident's needs that were identified in the comprehensive assessment for 1 of 6 residents (Resident #3) reviewed for comprehensive person-centered care plans. The facility failed to address Resident #3's 04/29/24 fall in her plan of care. This deficient practice could place residents at risk for injury with falls and not having personalized plans developed to address their needs. Findings include: Record review of Resident #3's electronic facility face sheet, dated 6/25/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to conduct the simplest tasks), muscle weakness, unspecified lack of coordination, and Dementia. Record review of Resident #3's quarterly MDS assessment, dated 3/31/24, reflected she scored a 3 on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-11-30 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure that food was discarded after its use by date. The facility failed to ensure food temperatures were taken and recorded prior to service. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. Findings included: During an observation on 11/28/2023 between 10:20 AM and 10:45 AM in the kitchen revealed: Refrigerator #1 1. 2 bags of cabbage with a use by date of 11/24/2023 2. 3 bell peppers that had a white substance on them that appeared to be mold 3. A plastic container that contained ranch with a prep date of 10/28/2023 and a use by date of 10/31/2023 4. 2 packages of boiled eggs with a use by date of 11/27/2023 5. 2 containers of ricotta cheese with a use by date of 11/22/2023 During an observation on 11/28/2023 between…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-30 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in permanently affixed compartments during medication storage inspection for 1 (cart #1) of 4 medication carts reviewed for storage in that: The facility failed to ensure medication cart #1 was locked and secured while unattended. This failure could result in a drug diversion. Findings included: During an observation on 11/28/23 at 01:58 PM, the medication cart at the nurse's station was unlocked with no staff present or within eyesight. There was also a resident sitting in her wheelchair at the nurse's station less than 6 feet away from unlocked medication cart in proximity to the medication. At 2:04 PM, staff nurses were observed coming from hall 100. The unlocked cart contained all prescription and OTC medications that included, but not limited to eye meds, stool softeners, antipsychotics, Insulins, Blood Pressure Medications, and Narcotics. During an interview on 11/28/2023 at 2: 04 PM, RN-A stated the open medication cart was hers and she was responsible for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-12 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to implement their written policies and procedures that prohibit and prevent abuse, neglect, and injuries of unknown source, to include identifying and investigating any such allegations for 1 (Resident #1) of 4 residents reviewed for abuse and neglect. The facility failed to conduct an investigation and report an injury of unknown origin to the appropriate State agency when notified Resident #1 had an injury of unknow origin of a large purple and yellow bruise on the right side of her forehead. This failure could place residents at risk of repeated injuries and abuse and/or neglect. Findings include: Record review of Resident #1's Face Sheet, dated 10/03/2023, revealed a [AGE] year-old female who was admitted into the facility on [DATE]. Resident #1's diagnoses included Displaced Supracondylar (break to the lower part of the bone) fracture of lower end of left femur (thigh bone), Osteoporosis (bone disease that develops when bone mineral density and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-12 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately to the State Survey Agency, one (Resident #1) of four residents reviewed for abuse and neglect. The facility failed to report an alleged injury of unknown origin to the State Survey Agency when Resident #1 was discovered with a purple and yellow bruise on the right side of her forehead approximately two inches in diameter This failure could place residents residing in the facility at risk of abuse/neglect not being reported. Findings include: Record review of Resident #1's Face Sheet, dated 10/03/2023, revealed a [AGE] year-old female who was admitted into the facility on [DATE]. Resident #1's diagnoses included Displaced Supracondylar (break to the lower part of the bone) fracture of lower end of left femur (thigh bone), Osteoporosis (bone disease that develops when bone mineral density and bone…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-12 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, including injury of unknown origin, were thoroughly investigated for 1 (Resident #1) of 4 residents reviewed for abuse and neglect. The facility failed to investigate when Resident #1's family reported a large purple and yellow bruise on the right side of her forehead that was unknown how the injury occurred. This failure could place residents residing in the facility at risk of not being protected or having a thorough investigation. Findings include: Record review of Resident #1's Face Sheet, dated 10/03/2023, revealed a [AGE] year-old female who was admitted into the facility on [DATE]. Resident #1's diagnoses included Displaced Supracondylar (break to the lower part of the bone) fracture of lower end of left femur (thigh bone), Osteoporosis (bone disease that develops when bone mineral density and bone mass decreases) without current pathological fracture (a break in a bone that is caused…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-12 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records reviews, the facility failed to maintain complete, accurately documented and readily accessible medical records, in accordance with accepted professional standards and practices, on each resident for 2 out of 3 (Resident #1 and Resident #6) reviewed for clinical records 1. The facility failed to document in Resident #1's clinical record the details involved around the incident when Resident #1's family member reported a large bruise on the right side of her forehead. 2. The facility failed to document in Resident #6's clinical record the details involved in the incident when Resident #6 was picked up to be transferred from his wheelchair to his bed and sustained 2 fractures in his right arm. This failure could place residents at risk for inaccurate or incomplete clinical records. Findings include: 1. Record review of Resident #1's Face Sheet, dated 10/03/2023, revealed a [AGE] year-old female who was admitted into the facility on [DATE]. Resident #1's diagnoses included Displaced…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-12 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to maintain infection control protocols to prevent infections for 1 of 1 resident (Resident #6) observed for catheter care needs. CNA-A used a peri-care cleaning wipe and cleaned catheter tubing toward the resident and not away from toward catheter bag to clean catheter tubing. These failures place residents at risk for unnecessary infections while in the facility. Findings include: Record Review of the resident #6's Medical Records revealed: The Face Sheet dated 10/10/2023, revealed she was an 82 yr. old male, admitted to the facility on [DATE], with a Diagnoses of Urinary Tract Infection. Resident #6's MDS, dated [DATE], Section C (Cognitive Patterns) revealed a BIMS score of 15 (cognitively intact). Resident #6's most recent Care Plan revealed, Resident #6 has an Indwelling Catheter, to provide catheter care every shift and as needed. Resident # 14's Orders revealed CATHETER CARE EVERY SHIFT MONITOR. During an observation on 10/12/2023…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2026-03-19 · tag F0943 — patternGive their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record reviews, the facility failed to provide training to their staff that at a minimum educates staff on dementia management for all new and existing staff for 1 of 18 (CNA F) staff reviewed for dementia management. The facility failed to ensure CNA F was educated on dementia management upon hire. This failure could place residents with dementia diagnosis at risk of being inappropriately cared for by uninformed staff. Findings included:Record review of personnel record for CNA F reflected a hire date of 12/30/2025. Further review of personnel record provided by HR reflected CNA F had no evidence she had completed the dementia management training upon hire or while working at the facility. During an interview on 03/19/2026 at 1:13 p.m., the ADMN stated her expectation would be for staff to have appropriate training per regulations. She stated the facility did not have a training policy and went by regulations for staff orientation and annual training. She stated she was sure she had done an in-service on the training but could not find one with CNA F's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2026-03-19 · tag F0944 — patternConduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to include as part of its QAPI program mandatory training that outlines and informs staff on the elements and goals of the facility QAPI program for all new and existing staff for 1 of 18 (CNA F) staff reviewed for training on QAPI. The facility failed to ensure CNA F was educated on the facility's QAPI program upon hire. This failure could place residents at risk of their quality of care not being improved upon when a known issue had occurred from staff not being informed on the goals and various elements of the QAPI program.Findings included:Record review of personnel record for CNA F reflected a hire date of 12/30/2025. Further review of personnel record provided by the HR reflected CNA F had no evidence she had completed QAPI training upon hire or while working at the facility. During an interview on 03/19/2026 at 1:13 p.m., the ADMN stated her expectation would be for staff to have appropriate training per regulations. She stated the facility did not have a training policy and went by regulations for staff orientation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2026-03-19 · tag F0946 — patternProvide training in compliance and ethics.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record reviews, the facility failed to include as part of its compliance and ethics program (1) an effective way to communicate the program's standards, policies, and procedures through a training program or in another practical manner which explains the requirements under the program; (2) annual training if the operating organization operates 5 or more facilities for all new and existing staff for 1 of 18 (CNA F) reviewed for training on compliance and ethics.The facility failed to ensure that CNA F was educated on compliance and ethics upon hire.This failure could affect residents and place them at risk of being uninformed of compliance and ethics program due to lack of staff training.Findings included:Record review of personnel record for CNA F reflected a hire date of 12/30/2025. Further review of personnel record provided by the HR reflected CNA F had no evidence she had completed compliance and ethics training upon hire or while working at the facility. During an interview on 03/19/2026 at 1:13 p.m., the ADMN stated her expectation would be for staff to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$8,190 in federal fines across 1 penalty.
- $8,190 — penalty dated 2023-10-12
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to THE ENSIGN GROUP — 342 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 3.2 | -1.2 vs chain |
| Health inspection | 3 of 5 | 2.8 | +0.2 vs chain |
| Staffing | 1 of 5 | 2.7 | -1.7 vs chain |
| Quality measures | 4 of 5 | 4.4 | -0.4 vs chain |
The other 341 homes this chain runs (chain average 3.2★, per CMS)
Showing 40 of 341; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| EASTLAND MEMORIAL HOSPITAL DISTRICT | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 04/01/2017 |
| MCGREW, PAMELA | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2015 |
| MCKNIGHT, MAXEY | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2016 |
| BURNAM, SOON | Individual | CORPORATE OFFICER | — | since 02/01/2015 |
| KEETCH, CHAD | Individual | CORPORATE OFFICER | — | since 03/01/2011 |
| TAYLOR, STEPHEN | Individual | CORPORATE OFFICER | — | since 07/01/2025 |
| FORREST HILL HEALTHCARE, INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2017 |
| ENSIGN SERVICES INC | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| RIO MESA HEALTH HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 02/01/2015 |
| STANDARD BEARER HEALTHCARE OP, LP | Organization | ADP OF THE SNF | — | since 02/01/2015 |
| THE ENSIGN GROUP INC | Organization | ADP OF THE SNF | — | since 02/01/2015 |
CMS files one row per role, so the 16 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.
6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $648K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in TX
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 675645. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-19, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.