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Victoria Gardens Of Allen

310 S Jupiter, Allen, TX 75002 · For profit - Limited Liability company · 120 certified beds · (972) 727-5850 Medicare & Medicaid certified

Call the home — (972) 727-5850 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 20 lower-level deficiencies on record (see below)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
Worth asking about
  • a high number of inspection citations overall (20) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • 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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 5 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
Dr Caring0.4 mi
411 W McDermott · (972) 227-3464 · Call to confirm hours
Pharmacy
Suiterx0.1 mi
307 S Jupiter Rd · (916) 242-8779 · Call to confirm hours
Grocery
3568 Charla Lane
Park
311 S Jupiter Rd · (214) 383-3145 · Typically dawn to dusk
Place of worship

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 5 of 5
Short-stay residentsrehab / post-hospital 4 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 improved from 3 to 4 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.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased15.9%15.8%15.4%typical
Long-stay residents who lose too much weight5.2%3.0%5.4%typical
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms4.1%2.4%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury1.4%3.3%3.3%better
Long-stay residents whose ability to walk worsened14.9%14.0%16.1%typical
Long-stay residents on antianxiety or hypnotic medication14.5%18.0%18.9%better
Long-stay residents given the seasonal flu vaccine98.6%98.0%95.3%typical
Long-stay residents with pressure ulcers2.6%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control8.1%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table6.8%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication2.1%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine90.9%88.0%79.4%better
Short-stay residents rehospitalized after admission18.2%25.7%22.6%better
Short-stay residents with an outpatient ER visit3.1%12.3%12.0%better
Long-stay hospitalizations per 1,000 resident days1.912.171.67worse
Long-stay outpatient ER visits per 1,000 resident days0.932.061.80better

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.

41.9% 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 58 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

41.9%U.S. median 51.5%
Got home and stayed home
11.8%U.S. median 10.7%
Went back to hospital
50.0%U.S. median 56.6%
Met the expected recovery
0.92U.S. median 0.31
Therapy hours / resident / day
0.39hours / resident / day
Physical therapy
0.40hours / resident / day
Occupational therapy
0.12hours / resident / day
Speech therapy

Met the expected recovery: 50.0% 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 32 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 0.92 therapist hours per resident per day in 2026Q1 — more than 96% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF41.9%CMS range 31.4–52.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.8%CMS range 8.0–16.410.7%Oct 2022–Sep 2024no 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 discharge50.0%56.6%Oct 2024–Sep 2025CMS 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 discharge59.4%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge40.6%50.0%Oct 2024–Sep 2025CMS 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 identified100.0%98.7%Oct 2024–Sep 2025CMS 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 setting100.0%100.0%Oct 2024–Sep 2025CMS 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 dischargenot 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened4.5%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.1%CMS range 4.8–16.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.981.02Oct 2022–Sep 2024CMS 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

0.28
RN hours/ resident / day
0.93
LPN hours/ resident / day
2.07
Aide hours/ resident / day
3.28
Total nurse hours/ resident / day
0.30
RN hoursweekends
54.1%
Total nursing turnover
71.4%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 87.2 residents a day — about 73% occupied, or roughly 33 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 3.28 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.28 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.07 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 2.80 hrs/resident/day on weekends vs 3.48 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.28 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

3
deficiencies at the latest standard inspection (2026-02-11)
2
at the previous standard inspection (2024-11-20)

Deficiencies are more than at the previous inspection — worsening. 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.

ABCDEFGHIJKL

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.

20 citations, most serious first. The 10 most serious are shown; the remaining 10 are one tap away and print in full.

  • Potential for harm · E2026-06-28 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure 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 safety 1 of 1 kitchen. 1. The facility failed to ensure food items were labeled and dated in the walk-in refrigerator.2. The facility failed to ensure expired food items were not in the walk-in refrigerator.3. The Dietary Manager failed to ensure lunch food temperatures were checked on the steam table line. These failures could place residents at risk of food contamination and food-borne illness.Findings included: During an observation on 06/28/26 at 9:12 AM, the following food items were observed in the walk-in refrigerator:Undated and unlabeled hamburger patties in an aluminum container;2 pounds of undated Sliced Smoke Turkey Breast in a resealable food storage bag;3 undated chicken salad sandwiches in resealable food storage bag;2 resealable plastic containers of chicken salad dated 06/14/26;1 resealable plastic container of chili dated 06/20/26;Sliced pickles in resealable food storage bag dated 06/23/26; and1…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-14 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor 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 ensure the resident had a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 1 of 4 residents (Resident #1 and Resident #2) reviewed for resident rights.The facility failed to ensure staff didn't tell Resident #1 to use her brief to go to the bathroom.This failure could place residents at risk of a decrease in quality of life.Findings include: Record review of Resident #1's face sheet, dated 04/14/26, reflected an [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included cerebral infraction-unspecified (type of stroke caused by a blockage of blood flow to the brain), Dementia (is a syndrome characterized by a decline in cognitive function, affecting memory, thinking behavior, and the ability to perform every day activities), depression unspecified (a person…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-14 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, permitted only authorized personnel to have access to the for 2 (MC#1 and TC#2) of 3 carts on 04/14/26.This failure could place residents at risk of drug diversion. Findings include:During an observation on 04/14/26 at 6:45 AM, it was revealed that the medication cart was left unlocked with the drawer facing outward at the nursing station. Surveyor did not observed staff at the nursing station or within view of Medication Cart#1 and Treatment Cart#2. Surveyor observed that Treatment Cart#2 was unlocked and was adjacent from the nursing station with the drawer's facing outward toward the hallway.During an interview on 04/14/26 at 7:00 AM, LVN G stated he had an emergency and stepped away from the medication cart. LVN G stated the treatment cart stayed unlocked for emergencies. LVN G stated residents with Dementia could take medication from the medication cart and it needed to be…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-02-11 · tag F0645 — pattern
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 all Pre-admission Screening and Resident Review (PASRR) level 1 residents with mental illness were provided with a PASRR level 2 evaluation for 1 of 2 residents (Resident #8), reviewed for resident assessment.Resident #8's PASRR level 1 screening form did not reflect mental illness, and the resident did not have a PASRR level II evaluation .This could place residents at risk of not receiving necessary specialized services to meet their individual needs.The findings were:Record review of Resident #8's quarterly MDS assessment, dated 01/15/2026, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's BIMs score was 15 indicating the resident's cognition was intact. Her diagnoses included Bipolar Disorder (mental condition marked by alternating periods of elation and depression), Generalized Anxiety Disorder (disorder characterized by feelings of worry, anxiety, or fear that are enough to interfere with…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-11 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    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, record review and interview, the facility failed to ensure that a resident receives treatment and care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one (Resident #95) of four residents reviewed for quality of care. The facility failed to ensure RN I completed wound cares to Resident #95 per physician orders. This failure placed residents at risk for the decline in quality of life and the wounds being infected or deteriorating.Review of Resident #95's face sheet dated 02/11/26 revealed he was a [AGE] year-old male, and he was admitted on [DATE]. Admitting diagnoses included, type 2 diabetes, acquired abscess of the left toe, peripheral vascular disease, and chronic osteomyelitis (Reduced blood flow (ischemia) from narrowed arteries limits immune response) left ankle and foot. Review of Resident #95's admission MDS assessment dated [DATE] reflected he had a BIMS score of 15, indicating no 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-11 · tag F0880 — failed to prevent and control infections — isolated
    Provide 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 maintain an infection control program designed to prevent the development and transmission of infection for one of six residents (Resident #75) observed for infection control. The facility failed to ensure CNA D completed hand hygiene while providing incontinence care to Resident # 75. This failure could place the residents at risk of infection.Record review of Resident #75's face sheet dated 02/11/26 reflected a [AGE] year-old female. She was admitted to the facility 01/14/26. Admitting diagnoses included hypertension, pressure ulcer to the sacrum area (located at the base of the spine) muscle weakness, neuromuscular dysfunction of the bladder (person lacks bladder control)and muscle wasting and atrophy. Review of Resident #75's care plan initiated 01/14/26 reflected Resident #75 had bowel/bladder incontinence related to disease process, impaired mobility and neurogenic disorder (conditions that target how your nervous system). Goal, 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-01-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure 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

    Based on observations, interviews, and record reviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 9 rooms (Rooms 104, 105, 108, 209, 212, 306, 307, and 312) of 30 rooms reviewed for accident hazards. The facility failed to ensure the needle sharps containers (which are specialized receptacles designed to safely dispose of sharp medical instruments that can cause injuries or infections) in Rooms 104, 105, 108, 209, 212, 306, 307, and 312 were emptied.This failure could place residents at risk of being injured by a needle, and exposure to bloodborne pathogens. Findings included: Observation on 01/20/26 from 10:00 AM to 11:00 AM revealed all resident rooms have a sharps container mounted inside the resident room by the door. Rooms # 104, 105, 108, 209, 212, 306, 307, and 312, (which were occupied by residents) were noted to have been filled past the Fill line to the point the security flap could not operate. Interview on 01/20/26 at 11:25 AM, LVN A stated the nurses were responsible for replacing sharp containers when…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-20 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard 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 reviews, the facility failed to ensure resident records were maintained for each resident that were complete; accurately documented, readily accessible; and systematically organized for 1 of 9 residents (Resident #1) reviewed for resident records.LVN B failed to document a telephone order from the physician for Resident #1's cough medicine, guaifenesin.This failure could result in residents not receiving the medication ordered. Findings included:Record review of Resident #1's quarterly MDS, date [DATE], revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included emphysema, lung cancer, end stage kidney disease requiring dialysis, and diabetes. Record review of Resident #1's care plan, dated [DATE], revealed she had a self-care deficit, had a tumor in her lungs, and went to dialysis every Monday, Wednesday, and Friday. Record review of Resident #1's EHR revealed the resident expired in the evening of [DATE] at the hospital. 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-07 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide 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 residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (Resident #1 and Resident #2) of five residents reviewed for Respiratory Care. 1. The facility failed to ensure that Resident #1's breathing mask for nebulization was properly stored on 12/07/2024. 2. The facility failed to ensure that Resident #2's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was properly stored on 12/07/2024. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: 1. Review of Resident #1's Face Sheet, dated 12/07/2024, reflected the resident was an [AGE] year-old female admitted on [DATE]. Resident #1 was diagnosed with chronic respiratory failure (airway to lungs becomes narrow…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-07 · tag F0880 — failed to prevent and control infections — isolated
    Provide 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 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 and to help prevent the development and transmission of communicable diseases and infections for one (Resident #2) of five residents reviewed for Infection Control. The facility failed to ensure that CNA B changed his gloves and performed hand hygiene while providing incontinent care to Resident #2 on 12/07/2024. This failure could place the residents at risk of cross-contamination and development of infections. Findings included: Review of Resident #2's Face Sheet, dated 12/07/2024, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #2 was diagnosed with muscle weakness and muscle atrophy (decrease in size of a body part). Review of Resident #2's Comprehensive MDS Assessment, dated 10/22/2024, reflected the resident was cognitively intact with a BIMS score of 13. Resident #2's Comprehensive…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 10 citations
  • Potential for harm · Dcited before2024-11-20 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    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 a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one (Resident #81) of eight residents reviewed for ADL care. 1. The facility failed to provide Resident #81 with timely incontinence care on 11/17/24. This failure could place residents at risk for a skin breakdown and infection. Findings included: Record review of Resident #81's annual MDS assessment, dated 08/08/24, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His BIMs score was 15 indicating his cognitive status was intact. His diagnoses included heart failure, cerebral palsy (group of conditions that affect movement and posture), and paraplegia (paralysis that affects the lower part of the body). The resident was dependent on staff for toileting. The resident was always incontinent of bowel and bladder. Record review of Resident…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-20 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    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 a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 (Resident #8) of 3 residents reviewed for pressure ulcers. The facility failed to provide wound care for Resident #8 on 11/16/24 and 11/17/24. This failure could place residents with pressure wounds at risk of the wound worsening, leading to increased pain, infection, delayed healing, serious complications including sepsis, reduced mobility, and a lower quality of life. Findings included: Record Review of Resident #8's admission Record and MDS assessment revealed a [AGE] year-old male, re-admitted to the facility on [DATE] with an original admission date of 06/25/2022. Resident's MDS revealed a BIMS score of 14 indicating he as cognitively intact. Record Review of Resident #8's Diagnosis Report and TAR revealed the following…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-09-28 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    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 the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 3 (Resident #9, Resident 47, and Resident #72) of 8 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #9 was shaved and not having facial hair. 2- Resident #47 had her fingernails cleaned and trimmed. 3- Resident #72 had his fingernails cleaned and trimmed. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: 1- Review of Resident #9's Quarterly MDS assessment dated [DATE] reflected Resident #9 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included paraplegia (paralysis of the legs and lower body), muscle weakness, lack of coordination, and type 2 diabetes mellitus. Resident #9 had BIMS score of 14, which indicated…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-09-28 · tag F0880 — failed to prevent and control infections — pattern
    Provide 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 maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 4 (Resident #14, Resident #34, Resident #66, and Resident#69) of 8 residents reviewed for infection control. The facility failed to ensure: 1- RN L disinfected the glucometer in between blood sugar checks for Residents #66 and #69. 2- MA M disinfected the blood pressure cuff in between blood pressure checks for Residents #14 and #34. These failures could place residents at-risk of cross contamination which could result in infections or illness. Findings included: 1- Record review of Resident #66's Quarterly MDS assessment, dated 09/03/23, reflected he was an [AGE] year-old male admitted to the facility on [DATE], with diagnoses including elevated blood pressure, and type 2 diabetes mellitus. He was unable to complete 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-28 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each 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 the resident received services in the facility with reasonable accommodation of resident needs and preferences for 1 (Resident #93) of 7 residents reviewed for call lights. The facility failed to ensure Resident #93's call button was within reach. This failure could place residents at risk for decreased quality of life, self-worth and dignity. Findings included: Review of the quarterly MDS dated [DATE] revealed Resident # 93 was a [AGE] year-old male admitted to the facility on [DATE]. The diagnoses for Resident #93 included: epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures, muscle weakness and atrophy (decrease in size and wasting of the muscle tissue; and diabetes. Review of the MDS revealed Resident # 93 required extensive two-person assistance with ADLs. Resident #93 was incontinent of bowel and bladder. The BIMS score for Resident #93 was 15, indicating that he was cognitively intact.…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-28 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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, interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 (Residents #47 and #93) of 24 residents reviewed for comprehensive care plans. 1. The facility failed to implement a care plan and implement interventions for Resident #47's ADL deficits of hygiene. 2. The facility failed to implement a care plan for Resident #93's specialized call light device. These failures could place residents at risk of not receiving individualized care and services to meet their needs. Findings included: 1. Review of Resident #47's Quarterly MDS assessment, dated 08/25/2023, reflected Resident #47 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included dementia, muscle weakness, and cognitive communication deficit.…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-28 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide 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, interview and record review, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care, was provided such care, consistent with professional standards of practice for one (Resident #250) of one resident reviewed for respiratory care in that: RN E failed to follow the procedure for tracheostomy care for Resident #250 when he failed to maintain a sterile/clean field for supplies necessary for care and failed to change his gloves and perform hand hygiene during tracheostomy care when going from dirty to clean multiple times. These failures could place residents with tracheostomies at risk for respiratory infections and the risk of lung infections. Findings include: Review of Resident #250's Face Sheet dated 09/27/23 reflected a [AGE] year-old female with an initial admission date of 08/29/23. Review of Resident #250's comprehensive MDS assessment, dated 09/14/2023, reflected the resident was unable to participate in the interview for cognition. Her…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-28 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide 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 interview, observation, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 (Nurses cart hall 400) of 2 carts reviewed for pharmacy services. The facility failed to ensure LVN C and RN K counted controlled drugs every shift change. This failure could result in an inaccurate controlled medication count, and drug diversion. Findings Included: Record review and random count observation of 400 hall nurse's cart with LVN C on 09/26/2023 at 12:28 PM revealed missing signatures for Off duty and On duty for 08/21/2023, 08/31/2023, 09/02/2023, 09/08/2023 of the narcotic count sheet. Interview on 09/26/2023 at 12:38 PM, LVN C stated he should have signed the narcotic sheet before and after counting the narcotics on 08/31/2023, and 09/08/2023. LVN C stated, I counted the narcotics but forgot to sign. LVN C stated this failure could potentially cause a drug diversion. Interview on 09/26/2023 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-28 · tag F0807 — failed to offer suitable drinks — isolated
    Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
    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 liquids consistent with the residents' needs, for one (Resident #85) of three residents reviewed for liquid inconsistency, in that: Resident #85 was not served nectar thickened coffee during her breakfast meal on 09/28/23. This failure could place residents who have dysphagia at risk for aspiration. Findings included: Review of Resident #85's quarterly MDS, dated [DATE], reflected Resident #85 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of coronary artery disease, diabetes, right-sided hemiplegia (paralysis that affects only one side of your body), aphasia (language disorder that affects a person's ability to communicate) and dysphagia. Resident #85 had a BIMS score of 0 indicating she was severely cognitively impaired. Resident #85 had a feeding tube and a mechanically altered diet which specified a required change in texture of food or liquids. The MDS also reflected Resident #85 was extensive…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-28 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    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 obtain from hospice the most recent hospice plan of care specific to each patient, hospice election form, the physician certification and recertification of the terminal illness specific to each patient and hospice medication information specific to each patient for one (Residents #24) of two residents reviewed for hospice. The facility failed to obtain the required hospice documentation for Resident #24 including hospice election form, the physician recertification of terminal illness, updated hospice plan of care and updated medication list from Hospice O. This failure could result in services and treatments not being coordinated. Findings included: Review of Resident #24's face sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of cerebral infraction (stroke), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs),…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to PRIORITY MANAGEMENT — 38 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 →

RatingThis homeChain avg
Overall 4 of 52.9+1.1 vs chain
Health inspection 4 of 53.2+0.8 vs chain
Staffing 1 of 51.6-0.6 vs chain
Quality measures 5 of 53.4+1.6 vs chain
The other 37 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Alpine Skilled Nursing and RehabilitationRuston, LA 1 of 5Bridgeport Medical LodgeBridgeport, TX 1 of 5Camelot Rehabilitation At Magnolia ParkLafayette, LA 1 of 5Colonial Oaks Skilled Nursing and RehabilitationBossier City, LA 1 of 5Hilltop Park Rehabilitation And Care CenterWeatherford, TX 1 of 5Pilgrim Manor Skilled Nursing and RehabilitationBossier City, LA 1 of 5Shreveport Manor Skilled Nursing & RehabilitationShreveport, LA 1 of 5St Joseph Skilled Nursing and RehabilitationMonroe, LA 1 of 5The Bradford Skilled Nursing And RehabilitationShreveport, LA 1 of 5The Guest House Skilled Nursing and RehabilitationShreveport, LA 2 of 5Booker T. Washington Skilled Nursing and RehabilitShreveport, LA 2 of 5Decatur Medical LodgeDecatur, TX 2 of 5Resthaven Living CenterBogalusa, LA 2 of 5Ridgmar Medical LodgeFort Worth, TX 3 of 5Broadmoor Medical LodgeRockwall, TX 3 of 5Camelot Of BroussardBroussard, LA 3 of 5Chateau St. James Rehab And RetirementLutcher, LA 3 of 5Louisiana Extended Care Hospital Of LafayetteLafayette, LA 3 of 5Mabank Nursing CenterMabank, TX 3 of 5Royse City Medical LodgeRoyse City, TX 3 of 5The Homestead of DenisonDenison, TX 3 of 5The Woodlands Healthcare CenterLeesville, LA 3 of 5Timber Springs Rehab and RetirementSpringhill, LA 4 of 5Belterra Health & RehabMcKinney, TX 4 of 5College Park Rehabilitation And Care CenterWeatherford, TX 4 of 5Jo Ellen Smith Convalescent CenterNew Orleans, LA 4 of 5Mansfield Medical LodgeMansfield, TX 4 of 5The Parks at Garland Healthcare and RehabGarland, TX 4 of 5Victoria Gardens of FriscoFrisco, TX 4 of 5Vista Ridge Nursing & Rehabilitation CenterLewisville, TX 4 of 5Windmill Village Rehabilitation & Care CenterLubbock, TX 5 of 5Camelot BrooksideJennings, LA 5 of 5Chateau D'Ville Rehab and RetirementDonaldsonville, LA 5 of 5Chateau Terrebonne Health Care CenterHouma, LA 5 of 5Grapevine Medical LodgeGrapevine, TX 5 of 5Spring Lake Skilled Nursing And RehabilitationShreveport, LA 5 of 5Springtown Park Rehabilitation And Care CenterSpringtown, TX

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 / managerTypeRoleShareSince
BAUDER FAMILY INVESTMENTS, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF33%since 04/01/2024
BOULWARE ST JAMES LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF33%since 04/01/2024
STEVEN BOULWARE FAMILY INVESTMENTS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF33%since 04/01/2024
BAUDER, KELLYIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 04/01/2024
BAUDER, MADISONIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 04/01/2024
BAUDER, PARKERIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 04/01/2025
BOULWARE, THOMASIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 04/01/2024
WALKER, KATIEIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 04/01/2024
PMG REALCO - ALLEN, LLCOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 04/01/2024
BRIDGEPOINTE FINANICAL SERVICES, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2024
INNOVATIVE NURSE CONSULTING, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2024
PRIORITY MANAGEMENT GROUP, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2024
PROGRESSIVE REHAB SOLUTIONS, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2024
AHMED, MD JEWELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/06/2021
BAUDER, WILLIAMIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2024
DOHLMAN, JOHNIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2024
BOULWARE, DOUGLASIndividualADP OF THE SNFsince 04/01/2024
BOULWARE, SANDRAIndividualADP OF THE SNFsince 04/01/2024
BOULWARE, STEVENIndividualADP OF THE SNFsince 04/01/2024
MILLER, BOBBIEIndividualADP OF THE SNFsince 04/01/2024

CMS files one row per role, so the 36 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted.

8 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.

$8.0M
Net patient revenuemost recent cost report
-38.6%
Operating marginrevenue minus expenses
$447K
Related-party expense4% of expenses
Who pays — share of resident-days
Medicaid 74%Medicare 6%Other / private 20%

About 74% 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. This home reported $447K paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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 2023. 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

$313per resident / day
operating cost
$9,504per month
≈ monthly operating cost
$226per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). 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

Paying with Medicaid

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.

Typical monthly cost in Texas
$5,627/mo
Nursing home (semi-private)
$7,604/mo
Nursing home (private)
$5,666/mo
Assisted living

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 675882. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-11, 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.

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