Willowcreek Rehab and Nursing
4934 S 7Th St, Abilene, TX 79605 · For profit - Corporation · 96 certified beds · (325) 692-2172 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0570)
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $23,794 in federal fines (most recent 2025-02-27)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- nursing-staff turnover (58%) runs well above the national median (45%)
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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
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 | 5 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 5 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 | 12.9% | 15.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.4% | 3.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.4% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.0% | 2.4% | 6.5% | check this* — see note marked star 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 | 3.6% | 3.3% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 7.8% | 14.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 15.5% | 18.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.2% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 12.3% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 11.7% | 9.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 93.8% | 88.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 22.8% | 25.7% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 0.0% | 12.3% | 12.0% | check this* — see note marked star below the table |
| Long-stay hospitalizations per 1,000 resident days | 1.77 | 2.17 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.66 | 2.06 | 1.80 | typical |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
Met the expected recovery: 48.5% 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 33 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 0.17 therapist hours per resident per day in 2026Q1 — more than 16% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 9% 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.1%CMS range 7.0–16.0 | 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 | 48.5% | 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 | 42.4% | 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 | 48.5% | 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 | 100.0% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 | 1.9% | 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 | 0.0% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.15 | 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 96 beds and averages 76.0 residents a day — about 79% occupied, or roughly 20 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 2.74 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.41 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.69 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 2.44 hrs/resident/day on weekends vs 2.85 on weekdays — 15% thinner on weekends. RN hours go from 0.47 to 0.25 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 58% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
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.
24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.
- Immediate jeopardy · K2025-02-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 maintain hot water below 110°F for 5 of 8 (Resident #60's sink, RM17 E sink, East Hall shower room sink, Resident #168, Resident #167, and Resident # 14's shared sink and RM [ROOM NUMBER] E sink) bathroom reviewed for water temperature. 1. The temperature of sink in RM [ROOM NUMBER]E was 150°F. 2. The temperature of the East Hall Shower Room Resident 150°F. 3. The temperature of Resident #168, Resident #167, and Resident #14's shared sink was 140°F. 4. The temperature of Resident #60's sink was 136.4°F. 5. The temperature of sink in RM [ROOM NUMBER]E was 125.2°F. 6. The shower water temperature fluctuated, becoming hotter during use for Resident #23 and Resident #1 An Immediate Jeopardy (IJ) situation was identified on 02/25/2025. The IJ template was provided to the facility on [DATE] at 5:00pm. While the IJ was lowered on 02/27/2025 at 5:11 PM, the facility remained out of compliance at a severity level of no actual harm with a…
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 · E2026-05-06 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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 treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality and treat residents with respect and dignity for 3 of 12 (Residents # 62, Resident # 45, and Resident # 22 ) residents reviewed for dignity.The facility failed to prevent CNA E from standing over Resident# 62, Resident # 45, and Resident # 22 while assisting residents with eating their meal in the dining area.The facility failed to prevent CNA E from referring to Resident# 62, Resident # 45, and Resident # 22 who needed assistance with meals, as feeders.These failures could affect residents that require assistance with eating by placing them at risk of diminished quality of life and loss of their sense of self self-worth.BThe findings included:Review of Resident #62's Face Sheet dated 05/06/2026, reflected an [AGE]…
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 · E2026-05-06 · tag F0583 — failed to protect personal privacy — patternKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure residents had the right to send and receive mail, and to receive letters, package and other materials delivered to the facility or the resident through a means other than a postal service, including the right to privacy of such communications for 5 of 5 residents (confidential residents) reviewed for resident rights.The facility failed to ensure staff distributed mail received on Saturdays to the residents. This failure could result in residents not receiving mail in a timely manner and a diminished quality of life.Findings included:During a confidential group interview on an undisclosed date and time, 5 of 5 members in the group stated they did not receive mail on Saturdays because the girls in the offices did not work on Saturdays. They stated the mail was delivered Monday through Friday.During an interview on 05/06/2026 at 1:52 p.m., the AD stated she was responsible for getting the mail for the residents during the week Monday through Friday. She stated before today there was no person that was assigned to get…
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 · E2026-05-06 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
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 provide maintenance services necessary to maintain a sanitary, and comfortable environment for 5 of 20 (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], 104 and the East Conference Room) rooms observed for environmental conditions. The facility failed to ensure rooms 101,102, 103, 104 and the East side Conference Room sinks had hot water. These failures could place residents at risk for diminished quality of life, discomfort, and safety. Findings included: During an observation on 05/05/2026 at 12:16 p.m., East Side room [ROOM NUMBER] the water temperature in the sink with shared toilet room with room [ROOM NUMBER] hot water felt cold. The temperature was taken and the hot water temperature was 79.7 degrees F, after water was left running for 1 minute. During an observation on 05/05/2026 at 12:21 p.m., East Side room [ROOM NUMBER] the water temperature in the sink shared with room [ROOM NUMBER], the hot water felt cold. The…
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 · E2026-05-06 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
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 that residents were free of a med error rate of 5% or greater for 3 (Resident #10, Resident # 20 and Resident #25) of 5 residents reviewed for medication administration. The facility failed to ensure the medication error rate (11.5%) was less than 5%. This failure placed residents at risk of incorrect doses of medications and optimal therapeutic response. Findings included: Resident #10 Record review Resident #10's face sheet dated 5/6/26 revealed a [AGE] year-old female with an admission date of 12/12/2024. She had an active diagnosis of Dysphagia (difficulty swallowing) following cerebral infarct. Record review of Resident #10's physician orders dated 05/05/26 documented the following order: Acetaminophen (Tylenol) Oral Tablet 500 mg . Give 2 tablets via PEG-Tube every morning and at bedtime. During an observation on 05/05/2026 at 9:00 AM LVN A gave Tylenol 160 mg/5 ml gave 30 ml. Resident #20 Record review of Resident #20's face…
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 before2026-05-06 · 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, for 1 of 1 refrigerator in the secure unit. The facility failed to ensure the refrigerator on the secure unit that was used for patient snack storage was clean and temperatures were being checked and recorded. These failures could place residents at risk for foodborne illness, compromised nutritional health status, and being served food items that may not be fresh, taste stale, or be contaminated. The findings included:In an observation on 5/5/26 at 12:09 pm in the secure unit lobby, there was a small refrigerator that was soiled with dried food, spilled punch in the bottom, dust and dirt, and the ice had built up in the top freezer portion, and it needed to be defrosted on the inside. On the outside it was covered in dust on the top of the refrigerator. There was no temperature logs attached and no evidence of daily temperatures being taken. In an interview and observation with the DON on 5/5/26 at…
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 before2026-05-06 · 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 observation, interview, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 (Resident #70) of 3 residents reviewed for infection control.The facility failed to implement Enhanced Barrier Precautions for Resident #70 who had an Enhanced Barrier Precautions sign posted on her room door. This failure could affect residents and place them at risk for cross contamination and infections.The findings included:Record review of Resident #70's admission Record, dated 5/8/26 revealed a [AGE] year-old female with an original admission date of 1/21/23 with the latest admission date of 3/16/26. Her diagnoses included embolism and thrombosis of arteries of the lower extremities (blood flow to the legs is blocked) and cerebral infarction (stroke-blood clot in the artery in the brain). Record review of Resident #70's Quarterly MDS,…
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 before2025-12-19 · 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 reviewed for kitchen sanitation. 1. The facility failed to ensure staff practiced appropriate hand hygiene during meal prep.2. The facility failed to ensure staff wore effective hair restraints while in the kitchen area. These failures could place residents who received food from the kitchen at risk of cross contamination and food borne illness.The findings include: During an observation on 12/18/2025 at 10:35 a.m., observed Dietary Aide A as she wore a hair net that did not fit properly on her head. Dietary Aide A had approximately two (2) inches of hair across her forehead exposed and approximately four (4) inches of hair on the back of her neck exposed from the hairnet that hung down her neck. During an observation on 12/18/2025 at 10:40 a.m., observed [NAME] B's hair net did not cover her entire head and she had approximately two (2) inches of hair exposed around the circumfuse of…
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 before2025-04-30 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard 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 record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 2 of 5 residents (Resident #'s 2 and 4 ) reviewed for accuracy of records, in that: RN A failed to document the wound care for Resident #2's open areas to his right and left buttocks on 4/12/25 during the 6 AM to 6PM shift. RN A failed to document that Resident # 2 had a privacy bag on his catheter bag , a catheter securement device to hold his catheter tubing in place, and that he had a size 16 French to beside drainage and catheter care was administered during the 6 AM to 6 PM shift on 4/12/25. RN B failed to document the wound care for Resident #4's open areas to her right and left buttocks on 4/12/25 during the 6 AM to 6 PM shift. LVN B failed to document the wound care for Resident #2's open areas to his right and left buttocks on 4/24/25 during the 6 AM to 6 PM shift. LVN B failed to document that Resident #2…
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 before2025-04-30 · 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, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1(Resident # 4) of 2 residents observed for wound care. The facility failed to ensure the wound care nurse washed or sanitized her hands between glove changes while performing incontinent care and wound care on Resident #4. These failures could place residents at risk of infections. The findings included: Review of Resident #4's electronic face sheet reflected the resident was a [AGE] year-old female who was initially admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses that included: right side hemiplegia ( paralysis on one side of the body), and aphasia (inability to understand or produce speech). Record review of Resident #4's Annual MDS assessment dated [DATE], revealed…
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 · E2025-02-27 · tag F0570 — patternAssure the security of all personal funds of residents deposited with the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to purchase a surety bond, or otherwise provide assurance satisfactory to the secretary, to assure the security of all personal funds of residents deposited with the facility for 1 of 1 surety bonds reviewed. The facility failed to ensure that the facility's $30,000.00 surety bond was enough to cover the $32,6635 total residents' trust fund account balance. This deficient practice could affect all residents who deposited personal funds with the facility, and place residents at-risk of their personal funds not being assured. The findings included: Record review on 02/27/2025 of the facility's Bond Execution Report revealed bond amount $30,000 processed date 06/04/2024. Record review 02/27/2025 of facility's Bank Account Statistics Report with date range 10/01/2024 to 12/31/2024 revealed average balance $32,266.35. During an interview on 02/27/2025 at 3:10 PM the ADM stated he did not know why the surety bond amount was less than the average balance reported. The ADM stated it could be to the transition to Deluxe Health Care…
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 13 citations
- Potential for harm · E2025-02-27 · tag F0680 — patternEnsure the activities program is directed by a qualified professional.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to ensure the activities program was directed by a qualified professional who was a therapeutic recreation specialist or an activity professional for 1 of 1 activity director (AD) reviewed for qualifications. The facility failed to ensure the AD was a qualified therapeutic recreation specialist or an activities professional that met state licensing requirements. This failure could place residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interests/preferences of each resident. The findings included: Review of the AD's employee file revealed the AD took the position on January 27, 2025, and had no evidence of certification or training as a qualified therapeutic recreation specialist or an activities professional that met state licensing requirements. During an interview on 02/25/2025 at 4:00 PM the AD stated she was new to the facility, and she had started on 01/25/2025. The AD stated she had not received her AD certification at this time and 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 · E2025-02-27 · tag F0712 — patternEnsure that the resident and his/her doctor meet face-to-face at all required visits.
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 the ensure physician visits were conducted within 2-7 days of admission, once every 30 calendar days for the first 90 calendar days for 3 of 24 residents (Resident #22, Resident #23, and Resident #50) who were review for physician visits. 1. The facility failed to have Resident #22 seen by a physician within 2-7 days of readmission [DATE]), once every 30 calendar days for the first 90 calendar days. 2. The facility failed to have Resident #23 seen by a physician within 2-7 days of readmission [DATE]), once every 30 calendar days for the first 90 calendar days. 3. The facility failed to have Resident #50 seen by physician within 2-7 days of readmission [DATE]), once every 30 calendar days for the first 90 calendar days. This deficient practice could lead to a decline in health status or untreated conditions. Findings included: Resident #22 Review of Resident #22's Face Sheet revealed a [AGE] year-old female initially admitted on [DATE] with a recent…
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 before2025-02-27 · 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 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. 1. Hair net was not used for the DA, while he entered the kitchen. 2. Hand hygiene was not performed by CNA-C and the AD while passing trays in the hallway. These failures could place residents that eat out of the kitchen at risk for contamination and food borne illnesses. Findings included: During an observation on 02/24/2025 beginning at 10:30 AM the facility kitchen revealed: 1. The DA entered through the back entrance door, walked through the kitchen, and out the front door of the kitchen with no beard cover on. 2. Hand hygiene was not used during the passing of trays in the hallways for CNA-C and the AD. During an interview on 2/24/2025 at 12:05 PM CNA-C on the MCU failed to perform hand hygiene when serving and setting up food between residents. CNA-C was also observed leaving the MCU to go to kitchen to get silverware for a resident. When she returned, she…
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 · D2025-02-27 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
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 inform residents in advance of the risks and benefits of proposed care and treatment for 1 of 10 residents (Resident #50) reviewed for resident rights. The facility failed to obtain a signed consent for admission to reside onto the facility's Memory Care Unit. This failure could affect residents who were placed and received care placed on the Memory Care Unit without informed consent. Findings included: Review of Resident #50's Face Sheet revealed a [AGE] year-old female initially admitted on [DATE] with a recent admission date of 09/04/2024. Resident #50's medical diagnoses included: need for assistance with personal care, cognitive communication deficit, dementia, psychotic disturbance, mood disturbance, and anxiety disorder. Review of Resident #50's annual MDS dated [DATE] revealed in Section C - C0500, BIMS Summary Score, a BIMS score of 00 indicating the resident was unable to complete the interview. Review of Resident #50's Comprehensive Care…
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 before2025-02-27 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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 develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care plan and provide a summary of their baseline care plan to residents for 1 (Resident #168) of 10 residents reviewed for care plan completion. The facility failed to complete Resident #168's baseline care plan within the required 48-hour timeframe. This failure could place residents who were newly admitted at risk for not receiving necessary care and services or having important care needs identified. Findings included: Review of Resident #168's Face Sheet revealed a [AGE] year-old male admitted on [DATE]. Resident #168's medical diagnoses included COPD (Chronic Obstructive Pulmonary Disease), alcohol dependence, nicotine dependence chronic pain, respiratory failure, and homelessness. Review of Resident #168's Annual MDS dated [DATE] revealed in Section C - C0500, BIMS Summary Score, a BIMS score of…
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 · D2025-02-27 · 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 observations, interviews, 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 5 medication carts reviewed for storage. The facility failed to ensure medication cart #1 was locked and secured while unattended. This failure could result in a drug diversion. The findings included: During an observation on 02/25/25 at 5:05 PM medication cart #1 was sitting against the wall with the drawers facing outwards unattended and unlocked. The button that locked on the medication cart was not pushed in and the drawer could open when pulled. There were no staff seen on the halls. RN A came walking up the hall. She stated the medication cart should not have been left unlocked and unattended. RN A stated the nurse responsible for the cart was RN B. RN A stated RN B was in the dining room assisting residents with their meals. RN A locked the medication cart #1 . During an interview on 02/26/2025 at 06:52 PM the DON stated her expectation was that the medication carts…
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 before2024-01-10 · tag F0655 — patternCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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 develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care of 3 (Resident #103, Resident #104, and Resident #202) of 8 residents reviewed for care plan completion. The facility failed to complete Resident #103's, Resident #104, and Resident #202 baseline care plan within the required 48-hour timeframe. This failure could place residents who were newly admitted at risk for not receiving necessary care and services or having important care needs identified. Findings included: Resident #103 Record review of Resident #103's electronic face sheet dated 01/10/2024 revealed resident was a [AGE] year-old female admitted on [DATE], a code status of full code, with diagnoses that included: Pneumonia (lung infection), End stage renal disease (advanced kidney disease), and dependence on renal dialysis (dialysis to remove wastes that kidneys are no longer able 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 · Ecited before2024-01-10 · 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 and interviews, 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 staff sanitized the thermometer while taking temperature of food. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. The findings included: During an observation on 01/08/2024 beginning at 11:30 AM [NAME] C removed the thermometer from the mashed potatoes and placed it in the Beef and Cabbage and then in the gravy. [NAME] C failed to sanitize the thermometer between taking the temperature of each food. During an interview on 01/09/24 at 10:45 AM the DM stated her expectation when taking temperatures of food was the thermometer should have been cleaned with an alcohol swab before placed in a food and after removed from item. The DM stated [NAME] C should have not been dipped into water between each use. The DM stated the cooks were responsible to take the temperatures, but she was responsible 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 · Ecited before2024-01-10 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for infection control procedures for 3 of 5 (#4, #17, and #44) residents reviewed for infection control. The facility failed to follow their Infection Control policy regarding CDC guidelines of performing the Flu test in conjunction with their COVID-19 testing. this failure could place residents at risk of the spread of infections. Findings included: Resident #4 Record review of Resident #4's electronic face sheet dated 01/10/2024 revealed resident was an [AGE] year-old female originally admitted on [DATE] and most recently admitted on [DATE] with diagnoses that included: COVID-19, Streptococcus Pneumoniae (a bacteria commonly inhabited in the respiratory tract). Record review of Resident #4's physician orders dated 01/07/2024…
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 · D2024-01-10 · 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 reviews, the facility failed to ensure residents were provided respiratory care received care consistent with professional standards of practice for 2 of 2 residents (Resident #11 and Resident #42) reviewed for oxygen administration. The facility failed to provide Oxygen (O2) in use sign on resident doorways for Resident #11 and #42. These failures could place residents at risk of not receiving appropriate respiratory care. Findings included: Resident #11 Record review of Resident #11's electronic face sheet dated 01/10/2024 revealed resident was an [AGE] year-old female originally admitted on [DATE] and most recently admitted on [DATE] with diagnoses that included: dementia (disease of the brain affecting memory and function), acute upper respiratory infection, difficulty in walking, unsteadiness on feet, lack of coordination, chronic obstructive pulmonary disease (lung disease interfering with breathing) and shortness of breath. Record review of Resident #11'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 · D2024-01-10 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
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 food was prepared in a form designed to meet individual nutritional needs for 1 of 1 lunch meal reviewed. The facility failed to ensure the recipe was followed when prepared pureed Seasoned Greens. This failure could place residents at-risk of inadequate nutrition and weight loss. The findings included: Record review of Resident #14's Quarterly MDS dated [DATE] revealed Section A Identification Informaiton- Resident #14 was a [AGE] year old female admitted on [DATE]; Section C Cognitive Patterns- Resident #14 had a BIMS score of 15 (Cognitively intact); Section I Active Diagnoses- Resident #14 had the following diagnosis cancer, heart disease, malnutrition; Section K- Swallowing/Nutritional status-Resident #14 had a mechanically altered diet. During an interview on 01/08/2024 Resident #14 stated she was on a pureed diet, and puree food was always bad. Resident #14 stated the puree food was gooey and sometimes it tasted like glue.…
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 before2024-01-10 · 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 interview, and record review the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurate for 2 (Resident # 8 and Resident # 17) of 5 residents reviewed for resident records. The facility failed to ensure smoking assessments were accurate for Resident #8 and Resident #17. This failure could place residents at risk of having errors in care and treatment. The Findings included: Record review of Resident #8's face sheet dated 01/10/2024 revealed resident was a [AGE] year-old female who was admitted on [DATE] with an original admission date of 02/26/2018 with diagnoses that included: Cerebral infarction (stroke), Major Depressive Disorder, right side paralysis and weakness. Record review of Resident #8's Quarterly MDS dated [DATE] revealed: Section C-Cognitive Patterns Resident #8 had a BIMS score of 7 (severe cognitive impairment); Section GG- Functional Abilities and Goals Resident #8 needs assistance…
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 · D2023-09-27 · 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
Based on interview and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse and neglect for 1 of 4 staff (CNA-B) reviewed for background screenings. The facility failed to provide evidence of completion of an annual EMR for CNA-B. These deficient practices could place residents at risk for abuse and neglect. The findings were: Review of the personnel file for CNA-B with a hire date of 06/06/2022 revealed last EMR was verified on 06/03/2022. During an interview on 09/26/2023 at 10:27 a.m., ADMN stated that EMR's were not verified. He was not aware the facility was supposed to verify EMRs yearly until new company took over the first of September. The failure was that EMR verification did not occur. ADMN stated that the affect on residents would be that not completing annual EMR's could result in staff working in the building that should not be allowed to work. Review of Human Resources Policy and Procedures Manual titled HR-103 TEXAS Background Screening Procedures Effective Date: 4-27-2021 - Supersedes all previous policies 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.
“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
$23,794 in federal fines across 1 penalty.
- $23,794 — penalty dated 2025-02-27
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.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| CHILDRESS COUNTY HOSPITAL DISTRICT | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 04/01/2017 |
| HOLCOMB, HOLLY | Individual | CORPORATE OFFICER | — | since 05/29/2021 |
| STRATTON, EMILEE | Individual | CORPORATE OFFICER | — | since 03/18/2018 |
| EVERGREEN HOLDCO LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/14/2025 |
| GOLD TX TRUST | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/14/2025 |
| SILVER TX TRUST | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/15/2025 |
| WILLOWCREEK REHAB AND NURSING LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/14/2025 |
| SILBERSTEIN, ARI | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 09/01/2023 |
| 4934 S. 7TH STREET LLC | Organization | ADP OF THE SNF | — | since 09/01/2023 |
| 4934 S. 7TH STREET TIC LLC | Organization | ADP OF THE SNF | — | since 09/01/2023 |
| GAMFAL LLC | Organization | ADP OF THE SNF | — | since 09/01/2023 |
| LICHTSCHEIN FAMILY 2012 TRUST | Organization | ADP OF THE SNF | — | since 09/01/2023 |
| SCHEINER FAMILY 2012 TRUST | Organization | ADP OF THE SNF | — | since 09/01/2023 |
| SCHEINER HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 09/01/2023 |
| BANES, MICHAEL | Individual | ADP OF THE SNF | — | since 12/09/2024 |
| GAO, MIN | Individual | ADP OF THE SNF | — | since 01/01/2011 |
CMS files one row per role, so the 17 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted.
11 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.
About 81% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
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 675350. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-06, 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 →
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