Heritage Convalescent Center
1009 Clyde St, Amarillo, TX 79106 · For profit - Corporation · 116 certified beds · (806) 352-5295 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0602), cited Jun 2025
- it has a citation for mishandling residents’ money or property (F0565)
- a high number of inspection citations overall (27) — 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)
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (57%) 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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 2 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 | 18.0% | 15.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 1.5% | 3.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.0% | 0.3% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 2.3% | 0.8% | 2.0% | worse 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 | 3.9% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 34.8% | 14.0% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 13.4% | 18.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 95.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.6% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 30.8% | 13.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.6% | 9.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.6% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 88.3% | 88.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 33.8% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 20.3% | 12.3% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.83 | 2.17 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.65 | 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.
62.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 162 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 15.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 38 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 0.32 therapist hours per resident per day in 2026Q1 — more than 53% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% 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 | 62.8%CMS range 54.6–66.9 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.2%CMS range 6.5–11.7 | 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 | 15.8% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 31.6% | 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 | 10.5% | 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 | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.5% | 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 | 6.3%CMS range 3.7–11.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.84 | 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 116 beds and averages 72.0 residents a day — about 62% occupied, or roughly 44 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 4.00 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.33 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.23 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.48 hrs/resident/day on weekends vs 4.21 on weekdays — 17% thinner on weekends. RN hours go from 0.36 to 0.27 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 57% 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.
27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.
- Potential for harm · E2025-12-04 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably 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 each resident had a right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 18 residents (Resident #15) reviewed for accommodation of needs in that:Resident #15 was not being provided with the correct size of adult brief.This failure could place residents at risk of not having met their needs and a decline in their quality of care and life.Findings included:Record review of Resident #15's face sheet, dated 12/03/2025, revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included, but were not limited to, Chronic Respiratory Failure with Hypoxia (failure of lungs to provide oxygen), Other lack of coordination, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypothyroidism (thyroid underperforming), Type 2 diabetes Mellitus (inability to process sugar), morbid (severe) obesity due to excess calories,…
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 · E2025-12-04 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to consider the views of a resident group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility for 5 of 7 anonymous residents.The facility failed to address a grievance put forth by the resident council regarding sheets not being changed on beds. This failure could lead to residents feeling unheard and unvalued in their place of residence.Findings Included:During a resident council meeting on 12/03/25 at 2:00 PM 5 of 7 attendees complained that their bed sheets were not being changed weekly while they were getting their showers, which was what was supposed to happened. One of the anonymous residents stated that she was a new admit and had only resided in the facility for one month. She stated that her bed sheets had only been changed one time since she had moved in. Another of the anonymous residents stated that a nurse would bring her the clean sheets and she would put them on herself and make her own bed. All five anonymous residents stated they…
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 before2025-12-04 · 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 the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure refrigerated, freezer, and pantry items were properly stored, labeled, and dated.This failure could place residents at risk of food-borne illness. Findings included:Observation of the freezer on 12/02/25 at 8:33 AM revealed the following:1. (1) small Ziploc containing French fries, no label or date.2. (1) small Ziploc containing chicken nuggets, no label or date.3. (4) boxes of juice, no label or date.Observation of the pantry on 12/02/25 at 8:26 AM revealed the following:1. (1) Ziploc bag with open cheese sauce mix bag inside, no label. Date on Ziploc was 5/4-6/4. 2. (1) bag of sloppy joe mix - expired December, 2024. DM threw this item in trash.3. (1) bag opened pork roast gravy mix, not in a sealed container.4. (1) box Jiffy corn bread mix in Ziploc, no label or date. Expiration date of 5/22/24.Observation of 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 · Dcited before2025-12-04 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 ensure all residents had the right to formulate an advanced directive for 1 (Resident #24) of 24 residents reviewed for advanced directives. Resident #24 had a DNR in her record that was signed incorrectly by the witnesses. The facility's failure to ensure the accuracy of a residents advanced directive could place residents at risk for not receiving healthcare as per their or their legal representatives' wishes.Findings included: Record review of Resident #24's face sheet printed [DATE] revealed she was a [AGE] year-old female resident admitted to the facility originally on [DATE] and readmitted on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interferes with daily functioning), Alzheimer's (a progressive disease that destroys memory and other important mental functions), and renal insufficiency (a condition where the kidneys do not function properly). In the section Advance Directives Resident #24 is listed as…
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 · D2025-12-04 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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 ensure residents the right to a safe, clean, comfortable, and homelike environment including clean bed linens for 2 (Resident #12 and Resident #78) of 18 residents reviewed for environment.1. The facility failed to ensure Resident #12 had clean sheets.2. The facility failed to ensure Resident #78 had clean sheets and a clean, sanitary room.These failures could lead to residents feeling neglected and/or to infection control issues.Findings Included:1. Record review of Resident #12's admission record dated 12/03/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to cognitive communication deficit (difficulty with one or more of the following: attention, memory, perception, language, problem-solving, and reasoning), weakness, need for assistance with personal care, and muscle weakness.Record review of Resident #12's quarterly MDS assessment completed on 10/13/25 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 · Dcited before2025-12-04 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights and including measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 (Resident #1 and Resident #24) of 18 residents reviewed for comprehensive care plans.1. The facility failed to include Resident #1's oxygen therapy in her care plan.2. The facility failed to include Resident #24's skin lesion in her care plan.These failures could lead to residents not receiving necessary care and/or treatment or receiving inaccurate care/and or treatment.Findings Included:1. Record review of Resident #1's admission record dated 12/04/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, paroxysmal atrial fibrillation (irregular heartbeat) and generalized anxiety…
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 · D2025-12-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the resident environment remains as free of accident hazards as is possible for 1 (Resident #11) of 18 residents reviewed for accident hazards.The facility failed to ensure Resident #11 did not have a tube of medicated cream and an aerosol can of sanitizing spray in her room.This failure could lead to harm if a resident was to ingest the cream and/or spray their skin with the sanitizing spray.Findings Included:Record review of Resident #11's admission record dated 12/03/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cognitive communication deficit (difficulty with one or more of the following: attention, memory, perception, language, problem-solving, and reasoning), COPD (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath, and fatigue), and need for assistance with personal…
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 · D2025-12-04 · 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 observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 (Resident #1) of 5 residents reviewed for respiratory care. -Resident #1 was receiving oxygen with no orders for her therapy. This failure could affect residents by placing them at risk for respiratory compromise and associated complications such as shortness of breath, confusion, respiratory failure, infection, and exacerbation of their condition. Findings included: Record review of Resident #1's face sheet dated 12/02/2025 revealed an [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), dementia (a group of thinking and social symptoms that interferes with daily functioning), generalized anxiety disorder (a mental health disorder characterized by feeling of worry, anxiety, or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-09-09 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure refrigerated and freezer items were properly stored, labeled, and dated.This failure could place residents at risk of food-borne illness. Findings included:Observation of the freezer on 09/09/25 at 9:54 AM revealed the following:1. (1) bag of unidentified food, no label or date. 2. (1) opened freezer bag of French fries, no label or date.3. (1) bag of hamburger patties, no label or date.4. (1) bag of hashbrowns, open to air, no label or date. 5. (1) bag of meat, no label or date.6. (1) opened, half-eaten ice cream sandwich, open to air, no label or date.7. (2) clear cups with lids, orange substance inside, no label or date. Observation of the walk-in refrigerator on 09/09/25 at 10:03 AM revealed the following: 1. (1) sealed container of vegetable base, no date or label.2. (6) packages of butter, one opened and in 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 · E2025-07-15 · 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 observation, interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices for 1 (Resident #1) of 6 residents reviewed for medical records. The facility failed to document wound care had been completed on 6 days of the previous 90 days that were reviewed. This failure could place all residents at risk of not receiving appropriate care through inadequate documentation possibly resulting in deterioration in condition, exacerbation of disease process, and increased risk of harm or injury.Findings include: Record review of Resident #1's clinical record revealed a [AGE] year-old-female admitted to the facility originally on 07/23/24 and readmitted on [DATE]. Resident #1's current diagnoses include peripheral vascular disease (a circulatory condition in which narrowed blood vessels recue blood flow to the limbs), atherosclerosis of native arteries of extremities (bilateral legs) (a medical condition where plaque builds up in 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.
Show the remaining 17 citations
- Potential for harm · E2025-06-03 · tag F0602 — failed to protect residents from theft of their belongings — patternProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents were free from misappropriation of property from 1 of 1 (LVN A) nurses reviewed. The facility did not prevent LVN A from taking narcotics from multiple unidentified residents. This failure could place residents at risk of continued misappropriation of property, increased pain, and lost trust in facility staff. Findings include: Resident #1 Record review of Resident #1's face sheet, dated 06/03/2025, revealed a [AGE] year-old male who was admitted to facility on 07/07/2023 with, but not limited to the following diagnosis: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (signs and symptoms of dementia and has a dementia diagnosis, but they lack any symptoms of behavioral disturbances), end stage renal disease (the final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-10-02 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
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 one of one kitchen observed for food storage, preparation, and distribution. Cooks C, D, and E failed to perform hand hygiene appropriately when preparing foods. This failure could place residents who ate food served by the kitchen at risk of food-borne illness from cross-contamination. Findings included: In an observation and interview on 9/30/24 at 11:30 am, [NAME] C was observed washing hands and putting gloves on. [NAME] C touched various kitchen surfaces in the kitchen. [NAME] C touched the prep counter, picked up a bag of ham chunks, attempted to open the bag, put the bag on the counter, and went to another area of the kitchen. [NAME] C opened the drawers in the kitchen and closed them then went to a different area of the kitchen, picked up the scissors and walked back to the preparation table. [NAME] C cut the bag of ham chunks open, then took disposable individual plastic serving cups and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-02 · tag F0726 — failed to have competent, trained nursing staff — patternEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
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 have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical well-being for 1 of 7 staff (RN J) reviewed for nursing services. The facility failed to ensure the following: -RN J used proper hand hygiene when administering medications -RN J observed resident consume their medications at time of administration. -RN J used proper hand hygiene while assisting an unidentified resident with eating their midday meal. -RN J locked and secured medication cart during medication administration. -RN J used proper hand hygiene or donning of gloves before breaking a pill with her hands for Resident #57. This facility's failure placed residents receiving medications at risk for drug diversion, drug overdose, and decrease efficacy of medications. These failures could expose residents to a risk of contracting viral infections, secondary infections and other communicable diseases.…
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 before2024-10-02 · tag F0761 — failed to label and store drugs safely — patternEnsure 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, it was determined the facility failed to ensure drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 (Hall 100 medication cart and Hall 400 medication cart) of 3 medication carts reviewed for medication storage. -Hall 100 medication cart left unlocked and unattended. -Hall 100 medication cart revealed 4.5 lose pills in the bottom of medication drawers. -Hall 100 medication cart had insulin for Resident #41 with no open date on her Humulin N insulin. -Medication was left on beside table for Resident #57 by RN J -Medication was left on beside table for Resident #10 by RN J -Medication was left on bedside table for Resident #7 by LVN F -Hall 400 medication cart revealed expired control solutions for calibration of the glucometer machine. The facility's failure placed residents receiving medication at risk for drug diversion, drug overdose, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-02 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of communication diseases and infections for 3 (Resident #15, Resident #22, and Resident #57) of 17 Residents. The facility failed to ensure the following: -RN J used proper hand hygiene while assisting an unidentified resident with eating their midday meal. -RN J used hand hygiene and donning of gloves before breaking a pill with her hands for Resident #57. -CNA H perform hand hygiene during incontinent care of Resident #15. -CNA I perform hand hygiene during incontinent care of Resident #22. These failures had the potential to affect residents in the facility by placing them at risk of contracting, spreading, and/or exposing them to bacterial or viral infections that could lead to the spread of communicable diseases. Findings included: Observation on 09/30/24 at 12:12 PM of RN J assisting unidentified resident with her mid-day meal. RN J took her left thumb…
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 · D2024-10-02 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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 observations, interviews, and record reviews, it was determined the facility failed to ensure each resident was provided the right to a dignified existence, self-determination, for 1 of 20 residents reviewed for Resident rights (Resident #15). -The facility failed to provide dignity and respect for Resident #15 by providing a privacy bag for her foley catheter. The facility's failure to ensure that each resident was treated with respect, dignity, and care in a manner that protects and promotes the rights of the residents. Findings included: Resident #15: Record review of Resident #15's clinical record, dated 10/02/2024, revealed that Resident #15 is a [AGE] year-old woman who was admitted to the facility on [DATE], with diagnosis to include type 2 diabetes mellitus without complications, mild cognitive impairment of uncertain or unknown etiology, pancreatic tumors, low potassium, depression, high blood pressure, asthma, perforation of intestine, retention of urine, history of blood clots, and stroke.…
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 before2024-10-02 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 residents had the right to formulate an advanced directive for 1 (Resident #10) of 20 residents reviewed for advanced directives. Resident #10 had a DNR in her record with no date for the physician signature. The facility's failure to ensure accuracy of resident medical records for advanced directives such as a DNR (Do Not Resuscitate), recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care could place residents a risk for not receiving healthcare as per their or their legal representatives wishes. Findings included: Resident #10 Record review of the clinical record dated 10/01/2024, for Resident #10 revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease with (acute) exacerbation, sleep apnea, lack of coordination, weakness, anemia, type 2 diabetes mellitus with elevated blood…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-02 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical and nursing needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #50) of 19 residents reviewed for care plans. The facility failed to update the wound care orders in Resident #50's care plan. This failure could put residents at risk of not receiving necessary care and treatment. Findings included: Record review of Resident #50's admission record dated 10/01/24 revealed a [AGE] year-old male originally admitted to the facility on [DATE] with diagnoses that included, but were not limited to, peripheral vascular disease (blood circulation disorder), type 2 diabetes (insufficient production of insulin, causing high blood sugar),…
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 before2024-10-02 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 observation, interview, and record review the facility failed to, based on the comprehensive assessment of a resident, ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive, person-centered care plan, and the resident's choices for 1 (Resident # 50) of 20 residents reviewed for quality of care. The facility failed to provide wound care for Resident #50 as ordered. This failure could place residents at risk of poor healing, worsening infection, and increased pain. Findings Included: Record review of Resident #50's admission record dated 10/01/24 revealed a [AGE] year-old male originally admitted to the facility on [DATE] with diagnoses that included, but were not limited to, peripheral vascular disease (blood circulation disorder), type 2 diabetes (insufficient production of insulin, causing high blood sugar), acquired absence of left leg below the knee, and acquired absence of right leg below knee. Record review of Resident #50's quarterly…
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 · D2024-10-02 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 PRN orders for psychotropic drugs were limited to 14 days for 1 (Resident #6) of 5 residents reviewed for unnecessary medication. Facility failed to ensure Resident #6's PRN order for psychotropic medication was limited to 14 days. This failure could place residents at risk of oversedation which could lead to falls and/or injuries as well as affect their quality of life. Findings Included: Record review of Resident #6's admission record dated 10/01/24 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, type 2 diabetes (insufficient production of insulin, causing high blood sugar), depression, and anxiety disorder. Record review of Resident #6's care plan completed 09/09/24 revealed she used antianxiety medications for anxiety disorder. The facility was to give the medications as ordered by the physician and monitor Resident #6 for side effects. Record review 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 · D2024-10-02 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 a safe, functional, sanitary, and comfortable environment for 2 (Resident #18 and Resident #60) of 20 residents reviewed for environment and 2 of 2 resident refrigerators. The facility failed to remove expired and rotten food from both resident refrigerators and failed to maintain them in sanitary condition. This failure could place residents at risk of contracting foodborne illness and/or feeling uncomfortable or degraded in their living environment. Findings Included: Record review of Resident #18's admission record dated 10/01/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, congestive heart failure (a progressive heart disease that affects the pumping action of the heart muscles resulting in shortness of breath and fatigue), mild intellectual disabilities (lower intellectual function leading to struggles with abstract thinking and social skills), and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-05 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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, interview, and record review, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice for 1 of 6 residents (Resident #1) reviewed for physician orders for treatments. The facility failed to follow physician orders and perform wound treatments as ordered for Resident #1. The failure could affect residents currently residing in the facility resulting in not receiving needed care to maintain optimum health and placing them at risk for injury and/or deterioration in their condition. Findings include: Record review of Resident #1's face sheet, printed 07/05/2024 revealed a [AGE] year-old male. Resident #1's MDS, dated [DATE] revealed a BIMS of 14 indicating no cognitive impairment. His functionality per his last MDS revealed he required extensive 2-person assistance to complete bathing, toileting, and lower body dressing. Resident #1 needed partial/moderate assistance with upper body dressing, and supervision or touch…
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 · F2024-03-06 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to designate a registered nurse to serve as the Director of Nursing on a full-time basis for the care and treatment of 65 of 65 residents. The facility failed to employ a DON from November 14, 2023, to present day. This failure had the potential to affect residents in the facility by leaving staff without supervisory coverage for coordination of events such as emergency care and disasters such as with flooding, power outage, tornado, fire, etc. Findings included: Record review of the facility's employee list, received 3/6/24, revealed there were eight RNs working in the facility but none of the RNs were designated as the DON. During an interview on 3/6/24 at 8:10 a.m., the Administrator stated they do not have a DON and have not had one since 11/14/23 when the last DON left. The Administrator stated she had not found a good candidate for the job yet. The Administrator stated LVN A keeps up with the DON duties for now and does in-services for staff. During an interview on 3/6/24 at 9:25 a.m., RN B stated they do not have 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 · Ecited before2023-10-10 · tag F0761 — failed to label and store drugs safely — patternEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in locked compartments for 2 of 2 medications. -Medication bubble pack was left unattended on medication cart on Hall 400 -Medication discovered was left on bedside table for Resident #1 These failures could place all residents at risk for obtaining medications that could cause adverse reactions. Findings included: Observation on 10/10/2023 at 9:28am revealed the medication cart in Hall 400 was unattended with a medication bubble pack left on the top of medication cart. Medication was turned over and reflected that the medication pack was full of Lasix medication. The Investigator stood next to medication cart for 5.5 minutes with no staff in sight. There was a resident sitting in a wheelchair next to the medication cart who asked, Is that medication mine? Investigator stated to resident that she was unsure who the medication belonged to. During an interview on 10/10/2023 at 9:33am, LVN A was asked…
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 · F2023-08-23 · tag F0575 — widespreadPost a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview the facility failed to post in a form and manner accessible to residents, resident representatives contact information including telephone numbers for the Long-Term Care Ombudsman program for 2 of 4 residents interviewed in a confidential group interview. The facility failed to ensure the Ombudsman Program information was posted in an area accessible for residents or resident representatives to see. This failure placed residents at risk of not being informed about the Ombudsman Program. Findings included: Observation on 8/21/2023 at 9:30 AM, the double doors leading to the required posting regarding the Ombudsman program were closed and not handicap accessible. Observation on 8/21/2023 at 1:30 PM, the double doors leading to the required posting regarding the Ombudsman program were closed and not handicap accessible. In a confidential interview on 08/22/2023 at 2:00 PM, 2 of 4 residents said they did not know who their ombudsman was and were not sure how to contact the Ombudsman. They also stated that they did not know where to find…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-08-23 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure freezer items were properly stored, labeled, and dated. 2. The facility failed to ensure dented cans were not in circulation. 3. The facility failed to ensure pantry foods were properly stored, labeled, and dated. 4. The facility failed to ensure the pantry was free from bugs. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings include: Observation of the freezer on 8/21/23 @ 8:20 AM revealed the following: 1. (1) 9X12 disposable foil pan with saran wrap loosely covering top, corners open to the air, with no label or date with what appeared to be a fruit cobbler. 2. (1) box of frozen pizzas, not sealed and open to air. Observation of the walk-in pantry on 8/21/23 at 8:26 AM revealed the following: 1. (1) 7 lb. can of banana pudding dented and stored 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.
- Potential for harm · Dcited before2023-08-23 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review; the facility failed to ensure medications were stored in accordance with currently accepted professional principles for 1 of 3 medication carts (Rehabilitation Hall Cart) reviewed for medication storage. The Rehabilitation Hall Medication Cart contained an insulin pen that had no markings for which resident it was being used for and no date of when it was opened/accessed and when it would expire. The facility's failure to ensure medications were stored in accordance with currently accepted professional principles could result in a resident receiving the incorrect medication or a medication that would be ineffective for their treatment resulting in exacerbation of the resident's condition and disease processes. Findings include: During an observation on [DATE] at 02:29 PM of the Rehabilitation Hall medication cart, noted was a Flex Touch Tresiba Insulin Pen which was one of eight insulin pens present in the cart. There were no markings on the Flex Touch Tresiba…
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
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| STEBBINS HERITAGE, INC. | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; GENERAL PARTNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 01/23/2025 |
| DICK AND JOILUE STEBBINS SON'S TRUST | Organization | DIRECT OWNERSHIP INTEREST; LIMITED PARTNERSHIP INTEREST | — | since 08/04/1996 |
| STEBBINS, RICHARD | Individual | DIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; LIMITED PARTNERSHIP INTEREST; ADP OF THE SNF | — | since 10/01/1998 |
| BAILEY, JENNIFER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/01/2018 |
CMS files one row per role, so the 12 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $600K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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
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
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 455480. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-04, 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 →
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