Ussery Roan Texas State Veterans Home
1020 Tascosa Rd, Amarillo, TX 79124 · For profit - Limited Liability company · 120 certified beds · (806) 322-8387 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)
- a high payroll-based staffing rating (4/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Mar 2024
- 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 $11,216 in federal fines (most recent 2025-04-11)
- nursing-staff turnover (62%) 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) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
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 2 to 3 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 | 23.0% | 15.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.9% | 3.0% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.5% | 2.4% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 4.8% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 22.3% | 14.0% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 12.1% | 18.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 95.8% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.1% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 24.2% | 13.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.5% | 9.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 63.9% | 88.0% | 79.4% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.53 | 2.17 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.77 | 2.06 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Met the expected recovery: 50.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 36 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 0.34 therapist hours per resident per day in 2026Q1 — more than 57% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.6%CMS range 6.7–16.4 | 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 | 50.0% | 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 | 41.7% | 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 | 36.1% | 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 | 90.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.0% | 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 | 10.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.02 | 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 120 beds and averages 118.1 residents a day — about 98% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. 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 4.02 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.61 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.65 is at or above 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 3.36 hrs/resident/day on weekends vs 4.29 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.74 to 0.31 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 62% is well above the national median of 45%. 3 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.
28 citations, most serious first. The 11 most serious are shown; the remaining 17 are one tap away and print in full.
- Actual harm · G2025-04-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to ensure the residents environment remained free from accidents as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 12 residents (Resident #1) reviewed for accidents, hazards, and supervision. The facility failed to ensure Resident #1 did not elope from the facility. The noncompliance was identiified as Past Non-Compliance. The Immediate Jeopardy began on 3/7/25 and ended on 4/3/25. The facility had corrected the noncompliance before the survey began. This deficient practice could place residents at risk a serious injury or serious harm and placed residents at risk of heat or cold exposure, dehydration and/or other medical complications, or being struck by a motor vehicle. Findings included: Record review of Resident #1s Face Sheet, undated, documented a [AGE] year-old male was admitted to the facility on [DATE] with the following diagnoses: Sequelae of nontraumatic…
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 before2025-05-30 · 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. 1. The facility failed to ensure [NAME] F and [NAME] G 's hands were washed and gloves were changed during preparation of food. 2. The facility failed to ensure [NAME] E wore beard covers while in the kitchen. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings included: In an interview and observation on 5/28/25 at 11:30 am, [NAME] F was observed in the kitchen prep area using the blender to chop meat for the mechanical soft diets. [NAME] F picked up meat patties with her gloved hands and tore meat apart with her gloved hands. [NAME] F put the meat into the blender, then touched the blender buttons, blender lid and kitchen utensils. [NAME] F picked up a container and moved it to the blender. [NAME] F picked up the blender container. [NAME] F removed the lid and used a spatula to scrape…
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 before2025-05-30 · 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 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 9 of 32 residents (Resident #22, #35, #11, #70, #51, #25, #58, #107, and Resident #9) reviewed for infection control. -CNA A failed to use proper hand hygiene techniques in between assisting Resident #22, #35, #11, #70, and Resident #51 with cutting up their food. -CNA B failed to use proper hand hygiene techniques when assisting Resident #107 to eat after assisting Resident #9 with the cutting up of his meal. -CNA C failed to use proper hand hygiene techniques when assisting Resident #25 to eat after assisting Resident #9 to sit up in his wheelchair. This failure could place residents at an increased risk for potentially exposing them to bacterial or viral infections that could lead to the spread of communicable diseases. Findings included: During an observation on 05/28/25 at 12:25 PM CNA A was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-30 · 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 observation, interview, and record review the facility failed to ensure each resident had a right to a dignified existence and to treat each resident with respect and dignity for 1 (Resident #63) of 24 residents reviewed for resident's rights. The facility failed to keep Resident #63's catheter bag covered with 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 include: Record review of Resident #63's face sheet dated 05/28/2025 revealed a [AGE] year-old male admitted to the facility on [DATE]. He had diagnoses that included, but were not limited to, cerebral infarction(stroke), dysphagia (difficulty swallowing in mouth and throat), unsteadiness on feet, abnormalities of gait and mobility, muscle weakness, paranoid schizophrenia (serious mental health disease causing misinterpretation of reality), post-traumatic stress disorder, generalized anxiety disorder (a group of mental…
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 · D2025-05-30 · 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 provide a clean and comfortable environment for 1 of 24 residents (Resident #117) reviewed for environment. -Resident #117 had his evening meal tray left in his room until the next AM. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment. Findings include: Record review of Resident #117's clinical record revealed an [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include myocardial infraction (heart attack), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), heart failure (a chronic condition in which the heart dose not pump blood as well as it should), basal cell carcinoma of the skin (cancer that begins in the lower part of the epidermis (the outer layer of the skin), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), 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 before2025-05-30 · tag F0641 — isolatedEnsure 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 1 (Resident #1) of 24 residents reviewed for accuracy of assessments. Resident #1 had an active order for oxygen at 3 lpm via NC to maintain Oxygen sats above 90% dated 03/14/2025 and his MDS with a completion date of 05/08/2025 did not indicate he received oxygen while a resident. This failure could place residents at risk of not having their needs identified and therefore not receiving necessary care. Findings Included: Record review of Resident #1's admission record dated 05/28/2025 revealed a [AGE] year-old male originally admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia with behavioral disturbance (breakdown of thought process causing disruptive behavior), malignant neoplasm of unspecified part of unspecified bronchus or lung (cancer in the lungs or airways in the lungs where the specific location or type is not…
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 · D2025-05-30 · 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 needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences, for 1 (Resident #1) of 24 residents reviewed for respiratory care. Resident #1 had orders for oxygen at 3 liters per minute and was observed to have an empty oxygen tank for an hour while in the dining area. This failure could place residents who receive oxygen at an increased risk for receiving oxygen at the wrong rate which could lead to hypercapnia (too much carbon dioxide in the blood), pulmonary oxygen toxicity (damage to the lung lining tissues and air sacs), hypoxemia (low levels of oxygen in the blood, decreasing the oxygen supply to vital organs), and shortness of breath. Findings included: Record review of Resident #1's admission record dated 05/28/2025 revealed a [AGE] year-old male originally admitted to the facility…
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 before2025-05-30 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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 observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, administering, and documentation of all drugs and biologicals) to meet the needs of 1 out of 6 residents (Residents #97) who was observed for medication administration. -RN D administered medication to Resident #97 via nebulizer and left Resident #97 unattended. This failure can affect residents that receive medications resulting in adverse reactions to medication, deterioration in their health, exacerbation of their disease process, and/or hospitalization. Findings included: During an observation on 05/29/25 at 08:45 AM Resident #97 was lying in his bed with a nebulizer treatment going and no staff was present in room with the resident. Record review of Resident #97's face sheet, dated 05/29/2025, revealed Resident #97 was a [AGE] year-old male resident who was admitted to the facility on [DATE] with the diagnoses of heart…
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 before2025-05-30 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed, in accordance with State and Federal laws, to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 (Resident #20) of 24 residents reviewed for medication storage. The facility failed to ensure Resident #20 did not have access to 650 mg acetaminophen capsules. This failure could place residents at risk of injury due to ingesting non-prescribed medications. Findings Included: Record review of Resident #20's admission record dated 05/28/25 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it, stroke), unspecified glaucoma (eye condition that damages optic nerve and can lead to vision loss or blindness), major depressive disorder recurrent…
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 · D2024-09-13 · 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
Based on observation, interview and record review, the facility failed to provide treatment and care to residents in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for one of 11 residents (Resident #1) reviewed for quality of care. CNA L failed to ensure Resident #1 had catheter care on 08/20/2024 resulting in Resident #1's suprapubic catheter leak to go undetected, resulting in Resident #1 being left in a saturated brief and in a bed with urine satured bed linens. The noncompliance was found to be Past Non-Compliance (PNC). The noncompliance began on 08/20/2024 and ended on 08/21/2024 The facility corrected the noncompliance before the investigation began. This deficient practice could result in residents not receiving the necessary care to maintain optimum health and place them at risk of skin breakdown. Findings included: Record review of Resident #1's clinical record revealed a 69 -year-old male admitted to the facility originally on 08/04/22 with diagnoses to include MULTIPLE SCLEROSIS, 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 · Dcited before2024-07-25 · 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 drugs were stored and labeled in accordance with currently accepted professional principles for 1 of 2 medication rooms. -The facility failed to store Hydrocodone-Acet 325mg properly by putting them with non-controlled discontinued medication in Medication room [ROOM NUMBER] and then later putting the medication in an ADON's office. This failure could result in a drug diversion placing residents at risk of not getting their medications as ordered. Findings included: In an observation on [DATE] at 5:00 AM, revealed Medication room [ROOM NUMBER] had a black plastic bin where non controlled discontinued medications were stored. The black bin had a slit and a hole on the lid and a combination lock on the bin. In an Interview on [DATE] at 5:00 AM, LVN A stated that the medications that were in the bin in the medication room were over the counter, non-controlled, discontinued medications. All controlled medications stayed 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 · Fcited before2024-03-22 · 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 general sanitary conditions in the kitchen were maintained during preparation and serving of food. 2. The facility failed to ensure hairnets and beard covers were worn. 3. The facility failed to ensure the food items were properly stored, labeled, and dated. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings include: In an interview and observation on 3/4/24 at 8:15 am [NAME] A was observed in the kitchen preparing food with no beard cover. [NAME] A stated, Yes, I should have a beard cover on. I just did not grab one. My bad. In an interview and observation on 3/4/24 at 8:17 am, the DM was observed in the kitchen prep area with no beard cover over his beard and moustache. The DM stated, It is not a beard. It is just a 2-day growth. 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 · E2024-03-22 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 abuse, for 6 of 7 residents (Resident #'s 61, 73, 86, 90, 104 and 112) reviewed for abuse. This failure could place these residents at risk of continued abuse on the locked unit of the facility. The failure was identified as past noncompliance as the facility had instituted adequate corrective measures to prevent reoccurrence of the non-compliance. Findings included: On 3/4/24 at 9:02AM an interview with Resident #110 was attempted but was unable be completed due to resident's level of cognitive decline. Interviews with Resident #'s 61, 73, 86, 90, 104 and 112 were attempted, but were unable to be completed due to resident's level of cognitive decline. Record review revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis of, but not limited to, Alzheimer's Disease with Late Onset; Major Depressive Disorder, Recurrent Severe, without Psychotic Features; Anxiety 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.
- Potential for harm · Ecited before2024-03-22 · tag F0636 — patternAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
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 conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment for 1 of 23 residents (Resident #110) reviewed for accurate assessments. This failure could place residents at risk of not receiving the care needed to maintain their highest, most practicable, physical, social, and psychosocial level of well-being. Findings included: On 3/4/24 at 9:02AM an interview with Resident #110 was attempted but was unable be completed due to resident's level of cognitive decline. Record review on 3/4/24 at 2:19PM revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis of, but not limited to, Alzheimer's Disease with Late Onset; Major Depressive Disorder, Recurrent Severe, without Psychotic Features; Anxiety Disorder, Unspecified and Psychotic Disorder with Hallucinations due to known Psychological Conditions. Record review of a Nursing Progress Note dated 11/30/23 at 5:42PM indicated a 14-day PRN…
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 before2024-03-22 · tag F0641 — patternEnsure 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 an assessment accurately reflected a resident's status for 1 of 23 residents (Resident #79) reviewed for accuracy of MDS assessments. -The facility did not correctly identify anticoagulation therapy for Resident #79 on his MDS assessment. This failure to ensure accurate assessments could affect all residents by placing them at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services. Finding include: Record review of Resident #79's clinical record revealed a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include schizoaffective disorder, depressive type, dementia in other diseases classified elsewhere, unspecified severity, with psychotic disturbance, muscle weakness (generalized), anxiety disorder, unspecified, vascular dementia, moderate, with other behavioral disturbance, delusional disorders. Record review of Resident #79's last MDS, dated…
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 before2024-03-22 · 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 observation, interview and record review the facility failed to ensure residents had the right to and the facility promoted and facilitated resident self-determination through support of resident choice, which included but not limited to the right to make choices about aspects of his or her life in the facility that were significant to the resident for 3 of 20 residents (Resident #13, Resident # 37, anonymous resident) reviewed for self-determination. A. The facility failed to ensure Resident #13 was allowed to have cereal when he expressed, he would like cereal after breakfast. B. The facility failed to ensure Resident #37 was allowed to choose the type of foods he preferred when he expressed, he would like bacon at breakfast like all the other residents were served. C. In a confidential interview one resident stated he asked for toast and was told no by the DM. This failure could place residents at risk for being denied the opportunity to exercise his or her autonomy regarding things that 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.
- Potential for harm · D2024-03-22 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
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 review and revise the resident's care plan after each assessment for 1 of 23 residents (Resident #110) reviewed for care plan accuracy. This failure could place residents at risk of not receiving the care needed to maintain their highest, most practicable, physical, social, and psychosocial level of well-being. Findings Included: On 3/4/24 at 9:02AM an interview was attempted with Resident #110 but could not be completed due to resident's level of cognitive decline. Record review on 3/4/24 at 2:19PM revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis of, but not limited to, Alzheimer's Disease with Late Onset; Major Depressive Disorder, Recurrent Severe, without Psychotic Features; Anxiety Disorder, Unspecified and Psychotic Disorder with Hallucinations due to known Psychological Conditions. Record review of a Nursing Progress Note dated 12/4/23 at 3:19PM indicated the House Psychiatrist was notified of an incident…
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 before2024-03-22 · 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 drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 2 (Hall 800 medication cart and Hall 500 medication cart) of 4 Medication Carts. There was 1 medication bottle with no expiration date and 3 loose pills in the Hall 800 Medication Cart. There were 2.5 loose pills were in the Hall 500 Medication Cart. The facility's failure could result in residents not receiving an accurate dose of medication as well as not being maintained at their best therapeutic level. Findings include: On [DATE] at 10:09 AM Observation of Hall 800 Medication Cart with LVN H revealed 3 loose pills and an Aspirin bottle with no expiration date on the bottle. LVN H stated that all medications are to have an expiration date on the medication. Loose pills could not be identified by LVN H. 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.
- Potential for harm · D2024-03-22 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure the menus met the nutritional needs of the residents in accordance with established national guidelines, and failed to ensure menus were followed, and failed to ensure menus reflected input received by residents /groups for 3 of 3 days of menus reviewed. The facility failed to: A. Follow the menu from the Menu Management Corporation as written. B. Ensure lunch items served on 03/04/24 and 03/6/24 reflect what was on the DM's menu. C. Ensure all residents recieved Bread/Rolls for the 3/4/24 lunch meal. D. Condiments were available for residents' meals. These failures affected all residents that received meals from the facility kitchen and put them at risk for malnutrition, dissatisfaction of meals and weight loss. Findings include: In an interview and record review on 3/4/24 at 9:30 am, the DM provided and reviewed the following facility menu documenting the meals for the week. The menu read: Menu Management for the week of Winter Spring 2024…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-22 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
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. -MH failed to use proper hand hygiene techniques when preparing a beverage for himself in the dining area. -CNA L failed to use proper hand hygiene techniques when assisting 2 unidentified residents to eat during lunch meal service. These failures had the potential to affect all 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: During an observation on 03/04/24 at 11:50 AM revealed MH walking into the dining area with gloves on into the beverage preparation area of the dining area and obtaining a drink for himself. MH did not take off his gloves while doing this activity and then took the beverage with gloves still on and left the dining area. Hand…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-20 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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 provide routine and emergency drugs and biologicals to its residents, or obtain them for 1 of 1 residents (Resident #1) reviewed for medications as evidenced by: The facility failed to transcribe physician orders correctly when Resident #1 returned from the hospital with discharge orders. This failure could place residents at risk of not receiving care and treatment to address their medical condition. Findings included: Record review of Resident #1's face sheet indicated Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: hypertension, syncope and collapse, metabolic encephalopathy ( problem in the brain caused by a chemical imbalance in the blood), unspecified atrial fibrillation (irregular heart rate that causes poor blood flow), diabetes, dementia, depressive disorder, pseudobulbar effect( inapprpriate laughing or crying), hypo-osmality ( levels of electrolytes, proteins, and nutrients…
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 before2023-02-08 · 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 observation, interview, and record review, the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 3 of 4 medication carts (400 Hall, 500 Hall and 600 Hall) reviewed. The facility failed to ensure medication carts on the 400 Hall, 500 Hall and 600 Hall did not contain loose pills. This failure could place residents at risk for drug diversion, drug overdose, and accidental or intentional missed doses or administration of medications to the wrong resident. Findings include: During an observation on 02-07-2023 at 08:42 AM of the 400 Hall medication cart, 6 loose pills were found under blister packs. The following loose pills removed from the cart included: *2 tabs Carbidopa-Levadopa for Parkinson's, *1 cap Lubiprostone 24 mcg for constipation, *1 tab Wellbutrin for depression, *1 tab Finasteride 5 mg for benign prostatic hyperplasia, and *½ tab unknown medication. During…
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 before2023-02-08 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
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 conduct a comprehensive and accurate assessment of each resident using the resident assessment instrument (RAI) specified by CMS for 1 of 21 residents (Residents #9) whose records were reviewed for assessments. Resident #9 was on CPAP therapy for Obstructive Sleep Apnea effective 6/23/2022 and it was not assessed in his admission MDS dated [DATE]. These failures to ensure comprehensive and accurate assessments could affect residents by placing them at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services. Finding include: Resident #9 Record review of Resident #9's face sheet dated 2-6-2023 revealed an [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include chronic kidney disease (longstanding disease of the kidneys leading to renal failure), cerebral infarction (occurs as a result of disrupted blood flow to the brain), diabetes (a group 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 · Dcited before2023-02-08 · tag F0641 — isolatedEnsure 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 observation, interview, and record review the facility failed to ensure resident assessments accurately reflected the resident's status for 1 of 21 residents (Resident #49) whose records were reviewed for assessments. Resident #49 was assessed in his quarterly MDS dated [DATE] for having a catheter when he was not receiving catheter care. These failures to ensure comprehensive and accurate assessments could affect residents by placing them at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services. Findings include: Record review of Resident #49's face sheet dated 2-8-2023 revealed a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (a group of lung diseases that block air flow and make it difficult to breath), cognitive communication deficit (difficulty with language and how someone uses language), muscle wasting (the decrease in size of muscle tissue),…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-02-08 · tag F0645 — isolatedPASARR 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 ensure that each resident was screened for a mental disorder or intellectual disability prior to admission for 2 of 21 residents (Residents #67 and #79) reviewed for PASRR compliance. The facility failed to ensure that an initial PASRR screening (Level I screen) was completed for Resident #67 prior to admission to the facility. The facility failed to ensure that an initial PASRR screening (Level I screen) was completed for Resident #79 prior to admission to the facility. These failures could place residents at risk of not receiving specialized and/or habilitative services as needed to meet their needs and as required by law due to an inability to identify potential mental disorders or intellectual disabilities. Findings Include: Record review of Resident #67's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, schizoaffective disorder bipolar type (mental disorder in which…
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 before2023-02-08 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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 that include the accurate dispensing and administering of all dugs and biologicals to meet the need of each resident for 1 of 4 (Resident #31) residents reviewed for medication administration. The facility administered insulin to Resident #31 after it was expired. This deficient practice can affect residents that receive medications resulting in deterioration in their health, exacerbation of their disease process, and/or hospitalization. Finding include: Record review of Resident #31's face sheet dated 2-7-2023 revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include diabetes (a group of diseases that result in too much sugar in the blood), dementia (a group of thinking and social symptoms that interferes with daily functioning), muscle weakness, hypertension (a condition in which the force of the blood against the artery walls is too high), pain, anxiety (intense,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-02-08 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that are complete, accurately documented, readily accessible, and systematically organized for four out of 21 residents (Residents #17, #45, #50 and #94) reviewed for complete and accurate medical records. Residents #17, #45, #50, and #94 had Out-Of-Hospital DNR forms that were not accurately completed. This failure could place residents with advance directives at risk for not having their end-of-life wishes followed. Findings include: 1. Record review of Resident #17's face sheet, dated [DATE], revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cerebral infarction (a stroke during which the brain does not get the blood flow it needs), venous insufficiency (veins in legs and occasionally arms have trouble moving blood back to the heart, results in swelling and often pain), type 2 diabetes, high…
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 before2023-02-08 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
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 of 5 staff (CNA E and CNA F) observed for hand hygiene. -CNA E and CNA F failed to use proper hand hygiene techniques when providing incontinent care to Resident #54. This failure had the potential to affect all residents in the facility receiving incontinent care by exposing them to care that could lead to the spread of viral infections, secondary infections, tissue breakdown, communicable diseases, and feelings of isolation related to poor hygiene. Findings include: During an observation of incontinent care on 02/07/23 at 10:25 am for Resident #54, CNA E and CNA F entered room and introduced self to Resident #54. Door to resident #54 was closed, and privacy curtain was closed. All supplies were assembled before procedure. CNA F explained to Resident #54 they were going to change his brief.…
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
$11,216 in federal fines across 1 penalty.
- $11,216 — penalty dated 2025-04-11
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 TEXVET — 9 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.7 | +0.3 vs chain |
| Health inspection | 3 of 5 | 2.3 | +0.7 vs chain |
| Staffing | 4 of 5 | 3.9 | +0.1 vs chain |
| Quality measures | 4 of 5 | 4.0 | ≈ chain avg |
The other 8 homes this chain runs (chain average 2.7★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| BERKELY, JOHN | Individual | W-2 MANAGING EMPLOYEE | since 04/11/2016 |
| MCLEMORE, WILLIAM | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | since 10/16/2014 |
| CARE INNS OF TEXAS LTD | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 04/17/2007 |
| FELLBAUM, ERNEST | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 04/12/2016 |
CMS files one row per role, so the 5 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner 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.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in TX
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 676157. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-30, 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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