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Landmark of Amarillo Rehabilitation and Nursing Ce

5601 Plum Creek Drive, Amarillo, TX 79124 · For profit - Limited Liability company · 99 certified beds · (806) 351-1000 Medicare & Medicaid certified

Call the home — (806) 351-1000 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Nov 20231 actual-harm citation1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$160,948 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $160,948 in federal fines (most recent 2026-05-20)
  • its payroll-based staffing rating is low (2/5)
  • nursing-staff turnover (98%) 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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1000 Craig Dr · (806) 331-7905 · Call to confirm hours
Pharmacy
Walgreens0.3 mi
5709 W Amarillo Blvd · (806) 355-7209 · Call to confirm hours
Grocery
5601 W Amarillo Blvd · (806) 353-6464 · Call to confirm hours
Park
4401 W Hills Trail · (806) 378-3036 · Typically dawn to dusk
Place of worship
5511 Amarillo Blvd W · (806) 354-0232

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 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 increased22.8%15.8%15.4%worse
Long-stay residents who lose too much weight1.1%3.0%5.4%better
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 symptoms1.0%2.4%6.5%better 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 injury3.8%3.3%3.3%worse
Long-stay residents whose ability to walk worsened13.0%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication12.5%18.0%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers5.9%3.8%4.7%worse
Long-stay residents with worsening bladder/bowel control11.4%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table20.1%9.6%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.5%1.5%1.4%typical
Short-stay residents given the seasonal flu vaccine100.0%88.0%79.4%better
Short-stay residents rehospitalized after admission38.6%25.7%22.6%worse
Short-stay residents with an outpatient ER visit4.3%12.3%12.0%better
Long-stay hospitalizations per 1,000 resident days1.652.171.67typical
Long-stay outpatient ER visits per 1,000 resident days0.542.061.80better

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.

57.7% 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 55 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

57.7%U.S. median 51.5%
Got home and stayed home
10.3%U.S. median 10.7%
Went back to hospital
63.6%U.S. median 56.6%
Met the expected recovery
0.25U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 63.6% 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 22 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 0.25 therapist hours per resident per day in 2026Q1 — more than 35% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF57.7%CMS range 45.6–68.651.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.3%CMS range 6.8–14.010.7%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 discharge63.6%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 discharge59.1%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 discharge72.7%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 identified80.0%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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 worsened6.7%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 hospitalization6.8%CMS range 3.9–12.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.821.02Oct 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

0.54
RN hours/ resident / day
1.00
LPN hours/ resident / day
1.89
Aide hours/ resident / day
3.43
Total nurse hours/ resident / day
0.52
RN hoursweekends
97.6%
Total nursing turnover
90.9%
RN turnover

How full it usually is: this home is certified for 99 beds and averages 83.5 residents a day — about 84% occupied, or roughly 16 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 3.43 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.54 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.89 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 2.98 hrs/resident/day on weekends vs 3.61 on weekdays — 17% thinner on weekends. RN hours go from 0.56 to 0.52 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 98% is well above 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

9
deficiencies at the latest standard inspection (2026-03-26)
4
at the previous standard inspection (2025-01-15)

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.

28 citations, most serious first. The 12 most serious are shown; the remaining 16 are one tap away and print in full.

  • Immediate jeopardy · J2026-05-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 6 residents reviewed for accidents and hazards.The facility failed to ensure Resident #1 did not have access to a double-sided razor blade. Resident #1 used the razor blade to cut his left wrist, resulting in a 7 cm laceration on the inside of Resident #1's left wrist which required 23-26 stitches on the night of [DATE].The noncompliance was identified as PNC. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the investigator entered the facility.This failure could place residents at risk of harm or death. Findings Included:Record review of Resident #1's admission record dated [DATE] revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, type 2…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Actual harm · H2023-11-20 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
    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 received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 18 residents (Resident # 4) reviewed for pressure ulcers. The facility failed to prevent the development of one facility-acquired Stage III pressure injury for Resident #4. This failure could place residents at risk for worsening of an ulcer, infection, and a decreased quality of life. Findings included: Record review of Resident #4's face sheet reflected a [AGE] year-old female who was re-admitted to the facility on [DATE]. Resident #4 was admitted with diagnoses which included: Other Cerebral Palsy Other Acute Kidney Failure Type 2 Diabetes Mellitus Without Complications Other Seizures Mild Intellectual Disabilities Mild Protein-Calorie Malnutrition Morbid (Severe) Obesity Due to Excess Calories Schizoaffective Disorder,…

    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 · D2026-05-20 · tag F0627 — isolated
    Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave for 1 (Resident #1) of 5 residents reviewed for transfer/discharge rights.The facility failed to allow Resident #1 to return to the facility after he was admitted to a short-term psychiatric hospital following an apparent suicide attempt.This failure could place residents at risk of feelings of instability/insecurity. Findings Included:Record review of Resident #1's admission record dated 05/19/26 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, type 2 diabetes mellitus (insufficient production of insulin, causing high blood sugar), nicotine dependence, alcohol dependence in remission, major depressive disorder recurrent severe (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in…

    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 · Dcited before2026-03-26 · 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 all residents had a right to a dignified existence for 1 of 24 residents (Resident #56) observed for dining room experience when the facility failed to: Ensure Resident #56 was treated with respect, dignity and consideration when she failed to receive her noon meal at the same time as her table mates. This failure could place residents at risk of feeling neglected or ignored and could negatively impact residents' quality of life. Findings included:Resident #56 was a 95-y o female admitted to the facility on [DATE] with diagnoses of dementia (a decline in mental ability), diabetes ( a condition causing high blood sugar due to insufficient insulin production), dysphagia- oropharyngeal type ( difficulty initiating a swallow, moving food from the mouth to the throat ), Vitamin B deficiency ( ( when the body lacks sufficient B vitamins needed for metabolism, red blood cell production and nerve function), Vitamin D vitamin deficiency…

    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 · D2026-03-26 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe and clean environment for 1 (Resident #59) of 17 residents reviewed for environment. -Resident #59 had soiled washcloths left in her room for 29 hours. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment.Findings included:Record review of Resident #59's face sheet revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), seizures (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), hemiplegia (a condition characterized by sever or completed paralysis on once side of the body, typically resulting from brain damage), and depressive disorder (a common, serious mental health condition characterized by persistent sadness,…

    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 · D2026-03-26 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 the assessment accurately reflected the resident's status for 2 (Resident #18 and Resident #71) of 18 residents reviewed for accuracy of assessment.The facility inaccurately coded Resident #18 as having a bipolar diagnosis when he did not have a bipolar diagnosis.This failure could place residents at risk of receiving unnecessary care/medication or not receiving necessary care/medication.Findings Included:Record review of Resident #18's admission record dated 03/25/26 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Parkinson's disease (chronic and progressive movement disorder that initially causes tremors in one hand and stiffness or slowing of movement), dementia (a group of thinking and social symptoms that interferes with daily functioning), and anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness…

    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 · D2026-03-26 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to refer to the state designated authority all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 (Resident #9) of 18 residents reviewed for PASRR.The facility failed to refer Resident #9 to the state designated authority for a PASRR Evaluation due to his diagnosis of Major Depressive Disorder Recurrent Severe.This failure could place residents at risk of not receiving necessary services or of being harmed by residents who have not been screened properly for placement in a nursing home setting.Findings Included:Record review of Resident #9's admission record dated 03/25/26 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, personal history of traumatic brain injury and major depressive disorder recurrent severe (a mental disorder characterized…

    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 · D2026-03-26 · tag F0645 — isolated
    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 interview and record review the facility failed to perform a preadmission screening for individuals with a mental disorder and individuals with intellectual disability for 1 (Resident #18) of 18 residents reviewed for preadmission screening.The facility failed to ensure an accurate PL1 for Resident #18 prior to her admission on [DATE]. She was coded as not having mental illness when she did have mental illness.This failure could place residents at risk of not receiving needed services.Findings Included:Record review of Resident #18's admission record dated 03/25/26 revealed a [AGE] year-old female admitted to the facility with diagnoses that included, but were not limited to, schizoaffective disorder bipolar type (mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder), generalized anxiety disorder (inability to control constant worrying), and major depressive disorder single episode (a mental disorder characterized by persistent low mood, low…

    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 · D2026-03-26 · 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 residents who required respiratory care were provided such care consistent with professional standards of practice for 1 (Resident #5) of 18 residents reviewed for respiratory care.Resident #5 did not have physician orders for oxygen therapy. This failure had the potential to affect residents by placing them at risk for respiratory compromise and associated complications, including shortness of breath, confusion, respiratory failure, infection, and exacerbation of their condition.Findings included: Record review of Resident #5's clinical record revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease (COPD refers to a group of diseases that cause airflow blockage and breathing-related problems), type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), dementia (a group of thinking and social symptoms…

    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 · D2026-03-26 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to prepare, and serve foods using methods to ensure palatability and flavor for 1 of 4 residents with a pureed diet (Resident #56) when they failed to: A. Ensure facility staff prepared pureed foods for meal service using standardized recipes, and nutritive methods to ensure palatability, flavor and meal satisfaction. These failures placed Reside1 of 4 residents who ate food that was pureed and served by the kitchen at risk of meal dissatisfaction and potential weight loss. Findings included: In an interview and observation on 3/24/26 at 11:00 am, [NAME] C measured 4 servings of green beans with juice, 7 ladles of gravy and 6 slices of bread into the blender. During the puree process another 3 slices of bread were added to the puree. [NAME] C pureed the beans then added 2 more slices of bread to the puree before completing the puree. During a taste test of the green beans the green beans tasted like bread with a hint of gravy to this writer. [NAME] C was asked to taste the green beans. She reluctantly tasted 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-26 · tag F0812 — failed to store, cook, and serve food safely — isolated
    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, and serve food under sanitary conditions in 1of 1 kitchen when they failed to: Ensure facility staff wore hair restraints and beard guards while in the kitchen.These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings included: In an observation on 3/24/26 at 8:15 am, a sign posted on the main door of the kitchen stated, A hairnet must be worn at all times in the kitchen. Do not enter without putting on a hairnet. Do not cross the threshold without one. No Exceptions. In an observation and interview on 3/24/26 at 10:00 am, [NAME] A walked through the kitchen with his beard and sideburns sticking out of his beard cover. The beard cover did not cover the mouth, sideburns or the upper part of his bushy beard. He stated as far as he knew he was supposed to have a beard cover and hair net on while in the kitchen. When asked if the hairnet was supposed to cover all parts of the hair on his face he stated What am I supposed…

    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 · Dcited before2026-03-26 · 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 prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #65) of 17 residents observed for infection control. -Resident #65's oxygen nasal cannula was left on the floor for 23 hours. This deficient practice has the potential to affect residents by exposing them to the spread of infections, tissue breakdown, and feelings of isolation related to poor hygiene.Findings include: Record review of Resident #65's face sheet revealed he was a [AGE] year-old male resident admitted to the facility originally on 11/26/2024 and readmitted on [DATE] with diagnoses to include chronic respiratory failure (a long-term condition lasting over a month where the lungs cannot adequately supply oxygen to the flood or removed carbon dioxide, often resulting from chronic diseases like COPD),…

    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 16 citations
  • Potential for harm · Dcited before2025-05-22 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to establish a system of record of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintained periodically reconciled for 1 of 18 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure Resident #1's OxyContin Oral Tablet ER 12-hour abuse-deterrent 10mg-28 count was accounted for at the time of receiving from the facility's Pharmacy on 05/02/2025. This failure could place residents at risk of not receiving medication therapy that would be effective for their treatment, resulting in the exacerbation of conditions and disease processes. Findings included: Record review of Resident #1's admission record dated 05/21/2025 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included Cauda equina syndrome(compression of the nerve roots…

    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 · Dcited before2025-02-27 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pharmaceutical services to include the accurate dispensing and administering of drugs to meet the needs for 1 of 7 residents (Resident #1) reviewed for physician orders. The facility failed to accurately enter physician orders for Lamotrigine (a medication that is used to treat epilepsy and bipolar disorder) for Resident #1. The deficient practice could affect residents 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 included: Record Review of Resident #1's face sheet dated 02/27/2025 revealed a [AGE] year-old female admitted to the facility from the hospital on [DATE] and was sent back to the hospital on [DATE] and readmitted to the facility on [DATE] with diagnosis to include but not limited to other specified local infections of the skin and subcutaneous tissue, other seizures, mild cognitive impairment of uncertain 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-01-15 · tag F0812 — failed to store, cook, and serve food safely — widespread
    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, and serve food under sanitary conditions in 1of 1 kitchens when they failed to: A. Ensure stored food was properly labeled and dated. B. Ensure hairnets were worn. C. Ensure frozen foods were properly stored according to the label. These failures could place residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings included: In an observation and interview on 1/13/25 at 8:20 am, DA was observed in the kitchen dishwashing room, washing the dishes with no hairnet on. DA stated she had no hairnet on because she could not find any hairnets that morning. She stated all kitchen staff were to wear hairnets while in the kitchen. She stated the consequences of not wearing a hairnet in the kitchen were cross contamination. DA stated the DM had trained her to always wear a hairnet in the kitchen. An observation on 1/13/25 at 8:25 am, of the cooler located in the kitchen preparation area the following was observed: 1. An opened box of crinkle cut fries…

    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 · Ecited before2025-01-15 · tag F0761 — failed to label and store drugs safely — pattern
    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, interview, 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 on 3 of 3 medication carts and 1 of 2 medication rooms reviewed for medication storage. -LVN F left medications for Resident #4 unattended on top of her medication cart. -2C South medication cart contained 2 insulins for Resident #68 that were expired. Lantus and Humalog insulin both had open dates of 12/10/2024. -2C South Medication room refrigerator contained Acetaminophen 650mg suppositories for Resident #71 with an expiration date of 10/2024. -1C North Medication cart contained 1 loose pill identified as Benzonatate 100mg for Resident #45. -1C South medication cart contained the following: *1 loose pill identified as Citalopram 20ng for Resident #73, Arnuity Ellipta for Resident #73 with no open date written on inhaler or tray. *Trelegy Aero for…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-15 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure residents who were trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 18 residents (Resident #18) reviewed for trauma-informed care. The facility did not ensure Resident #18 had a trauma screening that identified possible triggers when Resident #18 had a history of trauma. These failures could put residents at an increased risk for severe psychological distress due to re-traumatization. The findings included: Record review of the face sheet, dated 01/15/2025, indicated Resident #18 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses of unspecified Dementia (disease that destroys memory and other important mental functions), post-traumatic stress disorder ( a mental health condition that can…

    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 before2025-01-15 · 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 prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communication diseases and infections for 2 (Resident #11, and Resident #27) of 18 Residents in that: 1. The facility failed to ensure Resident #27's catheter bag and tubing were kept off the floor and below the level of his waist. 2. The facility failed to ensure CNA G performed hand hygiene and a glove change during incontinent care of Resident #11. 3. The facility failed to ensure CNA C performed hand hygiene and glove changes while performing catheter care for Resident #27 as well as cross contaminating Resident #27's belongings. 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…

    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 · Dcited before2024-02-06 · tag F0812 — failed to store, cook, and serve food safely — isolated
    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 service safety in 1 of 1 kitchen observed. The facility failed to ensure that all staff were wearing proper protective hair restraints in the kitchen. This failure placed residents who ate food served by the kitchen at risk of food contamination caused by fallen hair. Findings included: An observation and interview on 02/06/2024 at 11:35 AM revealed the DM was in the kitchen prep area without a hair restraint; her hair was long and went past her shoulders. The DM stated that she was in her office and heard State was at the kitchen door and got nervous and forgot to put on her hair restraint. The DM's hair was down past her shoulders, the front half was pulled back in a hair tie. The DM stated everyone was supposed to wear a hair restraint while in the kitchen. The DM did not have an answer about a possible negative outcome. During an observation and interview on 02/06/2024 at 3:35 PM, the DA was in the kitchen prep…

    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 · Fcited before2023-11-20 · tag F0812 — failed to store, cook, and serve food safely — widespread
    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 the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure foods were properly stored, labeled, and dated. 2. The facility failed to ensure general cleanliness was maintained in the kitchen. 3. The facility failed to ensure beard covers were worn. 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 11/6/23 @ 8:40 AM revealed the following: 1. (1) box of pancakes, open to air. 2. (1) box of frozen sugar cookie dough, open to air. 3. (1) baggie of biscuits, not in original package, no label or date. 4. (1) box of dinner rolls, open to air. 5. Several baggies of meat, no label or date, not in original box. 6. (1) bag of biscuits, no label or date, not in original box. Observation of the kitchen food prep area and the Traulsen Cooler in the kitchen prep area on 11/6/23 at 8:45 am…

    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 · Ecited before2023-11-20 · tag F0761 — failed to label and store drugs safely — pattern
    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, interview and record review; the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles to include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 2 of 3 medication carts (1BEast and 1BWest medication carts) and 1 of 3 (1BEast/1BWest Medication room) medication rooms in that: 1. 3 loose pills were found in the 1BEast medication cart. 2. 16 loose pills were found in the 1BWest medication cart. 3. Refrigerator in medication room, shared by 1BWest and 1Beast, had a temperature at 29 degrees. 4. 5 Medications discovered in E-kit for 1BEast and 1BWest were expired. These failures could result in residents not receiving an accurate dose of medication as well as not being maintained at their best therapeutic level. Findings include: Observation on 11/06/23 at 10:55 AM of 1BEast Med cart with LVN F, revealed there were 3 loose medications in this cart. LVN F was only able to identify 1 pill, LVN F stated that it was Zoloft. Other 2 pills were…

    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 · Dcited before2023-11-20 · 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 each resident has a right to a dignified existence and to treat each resident with respect and dignity for 1 (Resident #180) of 18 residents reviewed for resident's rights. The facility failed to keep Resident #180's catheter bag covered in a privacy bag. This failure could lead to residents at risk of experiencing feelings of shame and/or embarrassment as well as having their right to privacy violated. Findings included: Record review of Resident #180's face sheet dated 11/08/23 revealed a [AGE] year-old male admitted to the facility on [DATE] for hospice respite. He had diagnoses that included, but were not limited to, malignant neoplasm of bladder (bladder cancer), malignant neoplasm of left lung (lung cancer), and cachexia (wasting disease resulting in weight loss, muscle loss, lack of appetite, fatigue, and decreased strength). Record review of Resident #180's MDS tab in his EHR revealed an Entry MDS dated [DATE]. Record review…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-20 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor 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 observation, interview and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 1 (Resident #36) of 18 residents reviewed for advanced directives in that: Resident #36's DNR was signed on [DATE]. The chart header stated that resident was a Full Code. This failure could place residents at risk for not receiving healthcare as per their or their legal representatives wishes. Findings included: Record review of the face sheet of Resident #36 revealed a [AGE] year-old male, who was admitted to the facility on [DATE]. Resident #36 was admitted to facility with the diagnosis of Type 2 Diabetes mellitus with unspecified complication, heart failure, chronic pancreatitis, paranoid schizophrenia, Cachexia (wasting disease resulting in weight loss, muscle loss, lack of appetite, fatigue, and decreased strength), weakness, and chronic obstructive pulmonary disease. Under the section Misc. Resident #36 had a signed DNR dated [DATE]. Interview on [DATE] 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-20 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to ensure that all alleged violations including abuse, neglect, exploitation or mistreatment, which included injuries of unknown source and misappropriation of resident property, were reported immediately but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury for 1 of 8 residents (Resident #31) reviewed for abuse and neglect. The facility failed to report an unwitnessed fall with injury for Resident #31. This failure could place residents at risk for physical and psychological harm, worsening injuries, and delay of care. Findings include: Record review of Resident #31's face sheet reflected a [AGE] year-old female who was originally admitted to the facility on [DATE] with a readmission of 7/24/23. Resident #31 had diagnoses which included malignant neoplasm of endometrium (uterine cancer), cirrhosis of the liver, chronic diastolic (congestive) heart failure, and Type 2 diabetes mellitus. 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-20 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 (Resident #52) of 18 residents reviewed for baseline care plans in that: Resident #52 was admitted to the facility with a gastrostomy tube (a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation) and her baseline care plan did not mention the tube. This failure could place residents in danger of not receiving necessary care. Findings Included: Record review of Resident #52's face sheet dated 11/08/23 revealed a [AGE] year-old woman admitted to the facility on [DATE] with diagnoses that included but were not limited to acute respiratory failure with hypoxia (a condition resulting from not enough oxygen in the tissues 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-20 · 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 observation, interview, and record review, the facility failed to maintain complete, accurate, readily accessible, and systemically organized medical records for 2 (Resident #36 and Resident #180) of 18 residents reviewed for medical records. 1. Resident #180 was admitted to the facility with a catheter and no physician's orders for catheter care. 2. Resident #36 was receiving antipsychotic injections bi-weekly outside of the facility and there was no documentation of said in his EHR. These failures could place residents at risk of not receiving appropriate care through inadequate documentation possibly resulting in deterioration in condition, exacerbation of disease process, overmedication, and increased risk of harm or injury. Findings included: 1. Record review of Resident #180's face sheet dated 11/08/23 revealed a [AGE] year-old male admitted to the facility on [DATE] for hospice respite. He had diagnoses that included, but were not limited to, malignant neoplasm of bladder (bladder cancer),…

    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 before2023-11-20 · 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 establish and maintain an infection prevention and control programs designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #180) of 18 residents reviewed for infection control in that: Resident #180's catheter bag and tubing were allowed to rest on the floor of his room. This failure could place residents at risk of infection. Findings included: Record review of Resident #180's face sheet dated 11/08/23 revealed a [AGE] year-old male admitted to the facility on [DATE] for hospice respite. He had diagnoses that included, but were not limited to, malignant neoplasm of bladder (bladder cancer), malignant neoplasm of left lung (lung cancer), and cachexia (wasting disease resulting in weight loss, muscle loss, lack of appetite, fatigue, and decreased strength). Record review of Resident #180's MDS tab in his EHR revealed an…

    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
  • No harm found · C2023-11-20 · tag F0732 — widespread
    Post nurse staffing information every day.
    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 post the following information on a daily basis: facility name, the current date, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift--registered nurses, licensed practical nurses, or licensed vocational nurses (as defined under state law), certified nurse aides-and resident census for one of one facility reviewed for posted nurse staffing information. The facility failed to post nurse staffing data as required in that it did not include the current date on posting, posting was dated 11/06/2023. This failure could place residents and visitors at risk of not being informed regarding the current day's nurse staffing levels. Findings included: During an observation on 11/08/23 at 10:24 AM the nurse staffing posting hanging on the wall behind the front desk in the entry way of the facility was not dated 11/08/2023, it was dated 11/06/2023. During an interview on 11/08/2023 at 10:27 AM the front desk…

    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.

    Nursing and Physician Services 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

$160,948 in federal fines across 2 penalties.

  • $13,070 — penalty dated 2026-05-20
  • $147,878 — penalty dated 2023-11-09

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to CREATIVE SOLUTIONS IN HEALTHCARE — 149 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 3 of 52.1+0.9 vs chain
Health inspection 3 of 52.7+0.3 vs chain
Staffing 2 of 51.1+0.9 vs chain
Quality measures 4 of 53.2+0.8 vs chain
The other 148 homes this chain runs (chain average 2.1★, per CMS)
1 of 5Afton Oaks Nursing and Rehabilitation CenterHouston, TX 1 of 5Arlington Heights Health and Rehabilitation CenterFort Worth, TX 1 of 5Beltline Healthcare CenterGarland, TX 1 of 5Bluebonnet Nursing & RehabilitationKarnes City, TX 1 of 5Bluebonnet Point WellnessBullard, TX 1 of 5Brentwood Terrace Healthcare And RehabilitationParis, TX 1 of 5Buena Vida Nursing and Rehab-San AntonioSan Antonio, TX 1 of 5Cottonwood Nursing & RehabilitationDenton, TX 1 of 5Countryview Nursing & RehabilitationTerrell, TX 1 of 5Dogwood Trails ManorWoodville, TX 1 of 5Downtown Health and Rehabilitation CenterFort Worth, TX 1 of 5Estates Healthcare and Rehabilitation CenterFort Worth, TX 1 of 5Fair Park Health & Rehabilitation CenterDallas, TX 1 of 5Five Points Nursing & Rehabilitation of College StCollege Station, TX 1 of 5Five Points at Lake Highlands Nursing and RehabDallas, TX 1 of 5Five Points of PflugervillePflugerville, TX 1 of 5Franklin Heights Nursing & RehabilitationEl Paso, TX 1 of 5Gilmer Nursing & RehabilitationGilmer, TX 1 of 5Grace Pointe Wellness CenterEl Paso, TX 1 of 5Graham Oaks Care CenterGraham, TX 1 of 5Granbury Care CenterGranbury, TX 1 of 5Greenhill VillasMount Pleasant, TX 1 of 5Heritage At Longview Healthcare CenterLongview, TX 1 of 5Huebner Creek Health & Rehabilitation CenterSan Antonio, TX 1 of 5Interlochen Health and Rehabilitation CenterArlington, TX 1 of 5Kenedy Health & RehabilitationKenedy, TX 1 of 5Kennedy Health & RehabLufkin, TX 1 of 5Lake Lodge Nursing & RehabilitationLake Worth, TX 1 of 5Lampstand Nursing and RehabilitationBryan, TX 1 of 5Lancaster Nursing & RehabilitationLancaster, TX 1 of 5Marine Creek Nursing & RehabilitationFort Worth, TX 1 of 5Mesa Vista Inn Health CenterSan Antonio, TX 1 of 5Mountain View Health & RehabilitationEl Paso, TX 1 of 5Navasota Nursing & RehabilitationNavasota, TX 1 of 5Normandy Terrace Nursing & Rehabilitation CenterSan Antonio, TX 1 of 5North Pointe Nursing and RehabilitationWatauga, TX 1 of 5Park Place Care CenterGeorgetown, TX 1 of 5Parkview Manor Nursing and RehabilitationWeimar, TX 1 of 5Peach Tree PlaceWeatherford, TX 1 of 5Pebble Creek Nursing CenterEl Paso, TX

Showing 40 of 148; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
CHILDRESS COUNTY HOSPITAL DISTRICTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 09/01/2017
DRIVER, JAMESIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2025
FAVOR, DEBRAIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2025
GARRISON, REAGANIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2025
HEAD, HOWARDIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2025
HOLCOMB, HOLLYIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICERsince 05/29/2021
INMAN, JOHNIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2025
JOHNSON, LARRYIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2025
PIERCE, BRIANIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2025
STRATTON, EMILEEIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICERsince 03/18/2018
HUGGINS, LINDAIndividualCORPORATE DIRECTORsince 12/01/2023
WILLIG, ZACHARYIndividualCORPORATE DIRECTORsince 01/01/2025
AMARILLO IV ENTERPRISES, L.L.C.OrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/14/2025
BLAKE, GARYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2023
BLAKE, MALISAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2023
CUNNINGHAM, TIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/14/2025
HENSON, HARRYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/14/2025

CMS files one row per role, so the 23 rows in the source record cover these 17 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.

$7.0M
Net patient revenuemost recent cost report
-20.5%
Operating marginrevenue minus expenses
$260K
Related-party expense3% of expenses
Who pays — share of resident-days
Medicaid 80%Medicare 6%Other / private 14%

About 80% 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 $260K 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

$259per resident / day
operating cost
$7,884per month
≈ monthly operating cost
$215per 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 455675. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-26, 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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