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Ware Memorial Care Center

1510 S Van Buren St., Amarillo, TX 79101 · Non profit - Corporation · 120 certified beds · (806) 373-0471 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Aug 20231 immediate-jeopardy citation$81,894 in federal fines1 Medicare payment denial
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (26% vs 45% nationally) — better care continuity
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Aug 2023
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $81,894 in federal fines (most recent 2025-02-24)
  • its payroll-based staffing score sits well above its independent inspection score

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
400 SW 14th Ave Ste 100 · (806) 337-4555 · Call to confirm hours
Pharmacy
1501 S Tyler St · (806) 373-2812 · Call to confirm hours
Grocery
1000 S Polk St · (806) 335-6360 · Call to confirm hours
Park
Sandborn Park, 1401 S Taylor St · (806) 378-3036 · Typically dawn to dusk

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 3 of 5
Long-stay residentspeople who live here 1 of 5
Short-stay residentsrehab / post-hospital 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating 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 increased30.8%15.8%15.4%worse
Long-stay residents who lose too much weight4.7%3.0%5.4%better
Long-stay residents with a catheter left in their bladder4.9%0.3%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection4.6%0.8%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms2.4%2.4%6.5%typical for the 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 injury5.5%3.3%3.3%worse
Long-stay residents whose ability to walk worsened40.4%14.0%16.1%worse
Long-stay residents on antianxiety or hypnotic medication35.9%18.0%18.9%worse
Long-stay residents given the seasonal flu vaccine98.8%98.0%95.3%typical
Long-stay residents with pressure ulcers2.1%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control29.0%13.4%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table15.2%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.7%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine88.3%88.0%79.4%better
Short-stay residents rehospitalized after admission25.5%25.7%22.6%worse
Short-stay residents with an outpatient ER visit9.3%12.3%12.0%better
Long-stay hospitalizations per 1,000 resident days2.142.171.67worse
Long-stay outpatient ER visits per 1,000 resident days0.742.061.80better

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.

55.7% 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 26 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

55.7%U.S. median 51.5%
Got home and stayed home
10.7%U.S. median 10.7%
Went back to hospital
62.7%U.S. median 56.6%
Met the expected recovery
0.15U.S. median 0.31
Therapy hours / resident / day
0.10hours / resident / day
Physical therapy
0.03hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 62.7% 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 67 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 0.15 therapist hours per resident per day in 2026Q1 — more than 13% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF55.7%CMS range 42.5–75.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.7%CMS range 7.0–17.110.7%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 discharge62.7%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 discharge61.2%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 discharge31.3%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 identified96.0%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 setting97.2%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay6.7%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 worsened0.0%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 hospitalization6.0%CMS range 3.4–11.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.621.02Oct 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

0.59
RN hours/ resident / day
1.62
LPN hours/ resident / day
3.63
Aide hours/ resident / day
5.83
Total nurse hours/ resident / day
0.29
RN hoursweekends
25.5%
Total nursing turnover
20.0%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 87.7 residents a day — about 73% occupied, or roughly 32 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 5.83 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.59 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.63 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 5.44 hrs/resident/day on weekends vs 5.99 on weekdays — 9% thinner on weekends. RN hours go from 0.72 to 0.29 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 26% is below the national median of 45%.

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

7
deficiencies at the latest standard inspection (2026-02-12)
7
at the previous standard inspection (2024-12-05)

Deficiencies are unchanged from the previous inspection. 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.

27 citations, most serious first. The 12 most serious are shown; the remaining 15 are one tap away and print in full.

  • Immediate jeopardy · J2025-02-24 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents receive care consistent with professional standards of practice, to prevent pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and once developed, failed to ensure necessary treatment and services to promote healing for one (Resident #1) of nine residents reviewed for pressure ulcers. The facility failed to: A. Ensure Resident #1 who was admitted to the facility without a pressure ulcer did not develop an unstageable pressure ulcer with eschar (a layer of dead skin tissue that forms over a wound) on her coccyx within two weeks of admission. B. Failed to notify the wound care nurse of the ulcer. C. Failed to accurately document Resident #1's skin conditions which caused delayed care for the ulcer. D. Failed to document descriptions of the pressure ulcer which put the resident at risk of worsening pressure ulcer due to not accurately documenting Resident #1's skin conditions.…

    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
  • Actual harm · G2023-10-06 · 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 observation, interview, and record review, the facility failed to ensure that the residents environment remained as free from accident hazards as was possible; and that each resident received adequate supervision to prevent accident hazards for one resident (Resident #1) of 7 residents observed for accident hazards. -CNA A transferred Resident #1 in an unsafe manner resulting in a small skin tear and a large bruise to her left lower leg. This failure could affect all the residents at the facility by placing them at risk for accidents that lead to injuries such as bruising, skin tears, fractures, subdural hematomas, and feeling of isolation. Findings include: Record review of the clinical record for Resident #1 revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include senile degeneration of the brain (a decreased in the ability to think, concentrate, or remember), heart failure (a condition in which the heart dose not pump blood as well as it should), dementia…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-16 · 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 provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #1) of 6 residents reviewed for medication administration.The facility failed to ensure LVN A stayed with Resident #1 until the medications she gave him were taken on the morning of 04/16/26.This failure could place residents at risk of harm due to not receiving necessary medications or receiving medications at the wrong time as well as taking medication that does not belong to them.Findings Included:Record review of Resident #1's admission record dated 04/16/26 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, persistent atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), depression (a mood disorder that causes a…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-02-12 · tag F0641 — pattern
    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 observation, interview and record review, the facility failed to ensure an assessment accurately reflected a resident's status for 4 (Resident #1, #2, #28, and #40) of 24 residents reviewed for accuracy of MDS assessments. -The facility failed to accurately assess Resident #1, #2, and #40 for the use of restraints on their MDS assessments. -The facility failed to accurately assess Resident #28 for the use of CPAP therapy on his MDS assessment. This failure to accurately assess a resident could place residents at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services. Findings include: Resident #1 Record review of Resident #1's face sheet printed 02/10/26 revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include heart failure (a chronic condition in which the heart dose not pump blood as well as it should), atrial fibrillation (an irregular, often rapid heart rate that commonly causes…

    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 · Ecited before2026-02-12 · tag F0755 — failed to provide safe pharmacy services — pattern
    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 provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 2 (Resident #46 and Resident #79) of 24 residents reviewed for medication administration.1. The facility failed to ensure LVN A stayed with Resident #46 until her medications were swallowed on the morning of [DATE].2. The facility failed to ensure LVN B stayed with Resident #79 until her medications were swallowed on the morning of [DATE].3. The facility failed to ensure the Southeast Hall medication cart did not contain expired eyedrops.4. The facility failed to ensure the Southwest Hall medication cart did not contain expired insulin.These failures could place residents at risk of harm due to not receiving necessary medications or receiving medications at the wrong time as well as taking medication that does not belong to them or is no longer…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-02-12 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 2 kitchens when they failed to: Ensure kitchen staff used proper hand washing and sanitation procedures when handling food. Ensure kitchen staff and other employees wore hair restraints and beard coverings while in the kitchen. This failure could cause decreased meal satisfaction and decreased meal consumption due to using unsanitary practices in the facility's kitchen and could affect all residents in the facility that receive meals from the facility kitchen. Findings included: In an observation and interview of the kitchen food prep activities on 2/10/26 at 8:50 am, [NAME] I was observed in the kitchen with his beard cover under his chin and not covering his moustache. He stated he had been aware it should have been covering the moustache and just forgot to pull the face covering up over his moustache. He stated food borne illness would be a consequence of not having the proper covering. In an observation of the kitchen prep area on 2/10/26 at…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-12 · 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 interview and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 1 (Resident #55) of 25 residents reviewed for advanced directives.Resident #55's DNR form lacked a dated notarial acknowledgment and therefore was not fully executed.This failure could place residents at risk of receiving medical treatment inconsistent with their or their legal representative's expressed wishes.Findings included:Record review of Resident #55's face sheet dated [DATE] revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses including but not limited to unspecified atrial fibrillation(irregular heart rhythm), drug induce subacute dyskinesia(movement disorder related to side effects of medications), peripheral vascular disease (narrowed arteries/reduce blood flow to limbs) and hypertension(high blood pressure). Resident #55 was identified as a DNR in the Advance Directive section.Record review of Resident #55's quarterly…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-12 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review; the facility failed to ensure medications were stored in accordance with currently accepted professional principles for 1 (the 1-Northwest Hall medication cart) of 10 medication storage areas reviewed for medication storage. -The 1-Northwest Hall medication cart has loose medication pills. The facility's failure could result in a resident receiving medications that would be ineffective for their treatment resulting in exacerbation of the resident's condition and disease processes.Findings included: During an observation on 02/11/2026 at 08:44 AM of the 1-Northwest medication cart with LVN E present. Noted two loose pills identified by the LVN E as Levothyroxine and Atorvastatin. During an interview on 02/11/2026 at 1:24 PM LVN E reported loose medication in a medication cart can result in a resident missing a dose of medication, they could run out of the medication early and the insurance might not refill it. This could affect the residents if they do not receive the dose of medication they need. During an interview on 02/11/2026…

    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 before2026-02-12 · 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 #11) of 4 residents observed for infection control. -LVN E did not perform hand hygiene properly while performing wound care for Resident #11. This deficient practice has the potential to affect residents by exposing them to care that could lead to the spread of infections, tissue breakdown, and feelings of isolation related to poor hygiene. Findings included: Record review of Resident #11's admission record dated 02/12/2026 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to included Parkinson's (a disorder of the central nervous system that affects movements to include tremors), dementia (a group of thinking and social symptoms that interfere with daily functioning), Osteoarthritis…

    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 · Fcited before2024-12-05 · 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 7 out of 8 resident snack refrigerators located in the residents dining rooms, reviewed for kitchen sanitation. 1. The facility failed to ensure food items were properly stored, labeled, and dated. 2. The facility failed to ensure refrigerators were free of expired foods, non-food items and staff items. 3. The facility failed to ensure cleanliness was maintained in the refrigerators. These failures could place residents who ate food served by the kitchen, and stored food in the resident refrigerators were at risk of food-borne illness. Findings include: North Side First Floor In an observation and interview on 12/3/24 at 8:25 am of the initial tour of the lower-level resident dining room on the North side called the North First Floor Dining there were 2 refrigerators in the dining room. The refrigerators were stainless steel and had freezers on the bottom portion of the refrigerator. There 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-12-05 · tag F0552 — pattern
    Ensure that residents are fully informed and understand their health status, care and treatments.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents had the right to be informed in advance if the risks and benefits of proposed care, or treatment and treatment alternatives or treatment options and to chose the alternative or options he or she prefers for 5 of 19 residents (Resident #13, #15, #47, #70, and #75) and 5 residents interviewed during an anonymous interview reviewed for self-determination. The facility failed to ensure Resident #13, #15, #47, #70, and #75 and 5 anonymous residents received requested bedrails for 10 days or more after requested by the resident or family. This failure could cause residents to feel uncomfortable and disrespected leading to feeling of anxiety, anger, isolation, and deterioration in general health conditions. Findings include: Resident #13 Record review of Resident #13's clinical record revealed a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include epilepsy (a disorder in which nerve cell…

    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 · E2024-12-05 · tag F0582 — pattern
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    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 each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of charges for those services, which included charges for services not covered under Medicare/Medicaid or by the facility's per diem rate for 3 of 3 residents (Resident #31, Resident #82, and Resident #240) reviewed for Medicare/Medicaid coverage. 1. The facility failed to ensure Resident #31, Resident #82, and Resident #240 were given a NOMNC (a notice that indicates when care is set to end from a home health agency, skilled nursing facility, comprehensive outpatient rehabilitation facility, or hospice) with information on how to appeal the decision when residents were discharged from skilled services prior to covered days being exhausted. 2. The facility failed to ensure Resident #31, Resident #82, and Resident #240 were given a SNF ABN (document that informs a Medicare beneficiary that Medicare…

    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
Show the remaining 15 citations
  • Potential for harm · Dcited before2024-12-05 · 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 an assessment accurately reflected a resident's status for 1 of 19 residents (Resident #1) reviewed for accuracy of MDS assessments. -The facility failed to accurately assess Resident #1 who was listed for having a urinary catheter on her 9-3-2024 quarterly MDS. This failure to accurately assess a resident could place residents 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 #1's face sheet printed 12-5-2024 revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include cerebrovascular disease (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), Lupus (an illness that occurs when the immune system attacks health tissue and organs),…

    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 · D2024-12-05 · 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 need respiratory care were provided such care consistent with professional standards of practice for 2 (Resident #6 and Resident #79) of 5 residents reviewed for respiratory care. The facility failed to change nebulizer tubing for Resident #6 for 4 months. The facility failed to change nebulizer tubing for Resident #79 for 6 months. This failure could affect residents on respiratory therapy by placing them at risk for respiratory compromise and associated complications such as shortness of breath, confusion, respiratory failure, and exacerbation of their condition. Findings include: Resident #6 Record review of Resident #6's clinical record revealed 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), chronic bronchitis(productive cough for more than 3…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-05 · 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 provide pharmaceutical services that included the accurate acquiring and dispensing of all drugs and biologicals to meet the needs of each resident for 1 (Resident #75) of 19 residents reviewed for medication therapy and 2 (the Rehabilitation and Long-Term Care medication room and the 1-North medication room) of 8 medication storage areas reviewed for medication storage. -LVN B left the morning medications with Resident #75 unattended and did not verify if Resident #75 took the AM medications. -the Rehabilitation and Long-Term Care medication room had an expired OTC medication. -the 1-North medication room had an expired OTC medication. The facility's failure to ensure medications were dispensed in accordance with currently accepted professional principles which could result in a resident receiving or not receiving the correct medication therapy that would be ineffective for their treatment resulting in exacerbation of the resident's…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-05 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review; the facility failed to store a controlled drug subject to abuse properly for 1 (the Rehabilitation and Long-Term Care medication room) of 8 medication storage areas reviewed for medication storage. The Rehabilitation and Long-Term Care medication room had a Schedule III narcotic stored improperly in the refrigerator. The facility's failure to ensure medications were stored properly could result in medication diversion leading to a resident not receiving ordered treatment affecting the resident's treatment and care leading to deterioration in their health. Findings included: During an observation on 12-4-2024 at 08:19 AM of the Rehabilitation and Long-Term Care medication room storage refrigerator revealed a container with Buprenorphine (a schedule III narcotic) 0.25mg (3 tablets present in the package) that were on the refrigerator shelf. The narcotic was not stored in the locked box provided on the refrigerator door. During an interview on 12-4-2024 at 08:32 AM LVN C reported that storing a narcotic in the refrigerator and not 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-02 · 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 interview and record review, the facility failed to maintain complete, accurate, readily accessible, and systemically organized records for 1 (Resident #1) of 8 residents reviewed for medical records. The facility failed to document the fall risk evaluation for Resident #1's history of falls within the last 90 days. This failure could place all residents at risk of not receiving appropriate care through inadequate documentation possibly resulting in deterioration in condition, exacerbation of disease process, and increased risk of harm or injury. Finding include: Record review of Resident #1's medical record revealed an [AGE] year-old-female admitted to the facility on [DATE]. Resident #1's current diagnoses include muscle weakness, history of falling, insomnia, unspecified dementia, unspecified severity, with other behavioral disturbance, hallucination, long term use of anticoagulants. Resident #1's last MDS, dated [DATE] was a quarterly with a BIMS of 13 indicating Resident #1 is cognitively intact.…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-10-25 · 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 1 of 1 kitchen when they failed to: A. Ensure stored food was properly labeled, dated, and stored. These failures placed all residents who ate food served by the kitchen at risk of food-borne illness. Findings included: An observation of the facility walk-in cooler on 10/23/23 at 8:07AM revealed: 2 watermelons, no date received. 1 Food Service box of head of Romaine lettuce; open to air; no date. 2 8-count packages of pancakes; no label; no date. 1 6-count box of thawed pork tenderloin; no label; no date. 2 boxes, 24-count each, blueberry muffins, no label; no date. 3 thawed briskets; no label; no date. 2 13-ounce bottles of mint flavoring; no date. An observation of the dry pantry on 10/23/23 at 8:33AM revealed: 3 red potatoes laying on the floor of the pantry. 1 50-pound box of red potatoes; sitting on floor; open; no date. 1 50-pound box of white potatoes; sitting on floor; open; no date. 3 12-count packages of hot dog buns, expiration date…

    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 · E2023-10-25 · tag F0700 — pattern
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    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 attempt to use appropriate alternatives prior to installing a side or bed rail for 7 (Residents #4, #6, #10, #17, #19, #23, and #61) of 18 residents reviewed for bed rails. The facility placed bed rails on the beds of Residents #4, #6, #10, #17, #19, #23, and #61 on the day the residents were admitted without attempting other interventions first. This failure could place residents at risk of entrapment or injury due to bed rails. Finding included: Record review of Resident #4's face sheet dated 10/24/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), hypertensive heart disease (heart problems that occur because of high blood pressure), and chronic atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Record review of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-25 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure each resident had a right to reside and receive services in the facility with reasonable accommodation of the residents needs and preferences for 1 of 18 residents (Resident #23) reviewed for accommodation of needs. Resident #23's call light was not within her reach. The call light's cord was wrapped around the bed rail and was placed at the top of the bed rail out of reach and sight of resident. This failure could place residents at risk of not having their needs met and a decline in their quality of care and life. Findings included: Record review of Resident #23's face sheet , dated 10/24/2023, revealed an [AGE] year-old female admitted on [DATE] with diagnoses that included, but were not limited to, psoriatic arthritis (swollen joints), venous insufficiency (swelling due to blood flow in legs), age-related osteoporosis (weak bones), age related cognitive decline and systemic sclerosis (stiff skin and organs). Record review of…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-25 · 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

    Based on interview, and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 1 (Resident #61) of 18 residents reviewed for DNR orders. Resident #61 had an Out-of-Hospital DNR order that was invalid, as the date of signature of the Physician, Medical Power of Attorney and Notary did not match. This failure could place residents with DNR orders at risk for receiving, or not receiving, life-saving measures that align with their medical preferences. Findings included: Record review on 10/24/23 at 9:50AM revealed that the DNR was signed by MPOA (Medical Power of Attorney), who was her family member, on 1/13/23. The Physician's signature was dated 1/13/22 and the Notary's signature had no date. The last section of the DNR states that all 3 (MPOA, Physician and Notary) must agree that the document has been completed accurately. All 3 had signed that section. In an interview at on 10/24/23 at 9:59AM the DON confirmed that there had been a Care Plan entry on 1/13/23 which changed Resident #63 from Full Code status to DNR. The DNR with…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-25 · 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

    Based on observation, interviews and record review the facility failed to provide a homelike environment, which allowed comfortable temperature levels for 3 of 5 residents in a confidential group interview. The facility failed to maintain comfortable temperature levels between 71 degrees and 81 degrees in 1 of 4 dining rooms at the facility. This failure could place residents at risk of an uncomfortable environment and diminish their quality of life. Findings included: Observation of 2nd floor South Dining Room on 10/23/23 at 12:13 PM, observation of thermostat located on the interior wall which divided the dining room revealed it was 68 degrees in the dining room where 19 of the 21 residents that were in the dining room were wearing a jacket or had a blanket covering them. Confidential interview and observation on 10/23/23 beginning at 12:16 PM resident was observed sitting in the 2nd floor South Dining Room, resident stated that she was cold. Confidential Interview on 10/24/23 at 10:00 AM, 3 out of 5 residents stated that the dining room and the activity room upstairs were always…

    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 before2023-10-25 · 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 observation, interview, and record review, the facility failed to ensure that the resident's assessment accurately reflected the resident's status for 1 (Resident #19) of 18 residents reviewed for accurate assessments. The facility failed to correctly code bed rails for Resident#19. The facility had bed rails incorrectly coded as restraints on the MDS Assessments of Resident #19. This failure could place residents at risk of receiving inaccurate/unnecessary levels of care. Findings included: Record review of Resident #19's face sheet dated 10/24/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, fibromyalgia (a chronic disorder characterized by widespread pain and other symptoms such as fatigue, muscle stiffness, and insomnia), hypertension (high blood pressure), and generalized muscle weakness. Record review of Resident #19's care plan dated 10/11/23 revealed a focus area of [Resident #19] is at risk for impaired skin integrity…

    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 before2023-10-25 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined 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 of 3 Medication Carts and one Treatment Cart. [DATE] at 8:59AM on Second floor NW Medication Cart, 3 loose medications were found in the second drawer of the Medication Cart 1 expired medication found in Treatment Cart located on the first floor NW Hall, in a room labeled 'Linen Closet.' 1 vial Insulin found open with no expiration date on Medication Cart #2 second floor SW Hall. This failure could place 81 residents receiving medications at risk for drug diversion, drug overdose, and accidental or intentional administration to the wrong resident which could lead to exacerbation of their disease process and deterioration in general health. Findings included: During observation and interview…

    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 before2023-10-25 · 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

    Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 25 resident (Resident #232) reviewed for infection control. 1. The facility failed to ensure that contact precaution signage was in place for Resident #232 who was positive for C-diff upon admission. 2. The facility failed to implement isolation precautions for a Resident #232 who was positive for C-Diff. This failure could place the residents at an increased risk for potentially exposing them to infections, which could lead to abdominal cramping, lethargy, increased risk for diarrhea, dehydration, and feelings of isolation. Findings included: Observation on 10/23/23 8:30 AM revealed that Resident #232 was not in room. Asked CNA where patient was, she stated he was eating breakfast but will be back in room after breakfast. Observation on 10/23/23 09:10 AM No posting was observed…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-03 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 interviews and record reviews, the facility failed to ensure resideents the right to be free from abuse and/or neglect for 1 (Resident #1) of 7 residents reviewed for abuse and/or neglect. CNA A yelled or spoke loudly at Resident #1. The facility's failure to provide a safe environment free of verbal abuse places residents at risk of psychosocial harm. Findings included: Record review of Resident #1's face sheet, dated 8/3/23, revealed Resident #1 is a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included but are not limited to unspecified dementia with other behavioral disturbance (deterioration of memory, language, and other thinking abilities), systemic lupus erythematosus (autoimmune disease possibly causing skin rash, erosion of joints or kidney failure), hyperlipidemia (high cholesterol), hypothyroidism (underactive thyroid gland). Record review of Resident #1's MDS (Minimum Data Set), Section C (cognition), dated 6/1/23, revealed an absent BIMS (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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2026-02-12 · tag F0640 — pattern
    Encode each resident’s assessment data and transmit these data to the State within 7 days of 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, within 7 days after completing a resident's assessment, encode the following information for each resident in the facility: A subset of items upon a resident's transfer, reentry, discharge, and death for 3 (Resident #49, Resident #53, and Resident #60) of 21 residents reviewed for assessments.1. The facility failed to encode a death in facility assessment for Resident #49 within 7 days of his death in the facility on [DATE].2. The facility failed to encode a discharge assessment for Resident #53 within 7 days of his discharge on [DATE].3. The facility failed to encode a death in facility assessment for Resident #60 within 7 days of her death in the facility on [DATE].These failures could place residents at risk of inaccurate medical records.Findings Included:1. Record review of Resident #49's admission record dated [DATE] revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included heart disease (a range of conditions…

    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

“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

$81,894 in federal fines across 1 penalty. 1 Medicare payment denial on record.

  • $81,894 — penalty dated 2025-02-24
  • Medicare payment denial — starting 2025-03-25 for 1 days

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

Who owns this facility

Owner / managerTypeRoleShareSince
BAPTIST COMMUNITY SERVICESOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF100%since 12/30/2022
ANDERSON, DARRELLIndividualCORPORATE DIRECTORsince 12/31/2019
BORDEN, PATRICKIndividualCORPORATE DIRECTORsince 12/31/2019
BOYKIN, LORIIndividualCORPORATE DIRECTORsince 12/31/2020
BYRD, ROBERTIndividualCORPORATE DIRECTORsince 12/31/2024
CARTWRIGHT, DONALDIndividualCORPORATE DIRECTORsince 12/31/2020
DUGGAN, BRADIndividualCORPORATE DIRECTORsince 12/31/2020
HAMILTON, HENRYIndividualCORPORATE DIRECTORsince 12/31/2021
HICKS, ANDYIndividualCORPORATE DIRECTORsince 12/31/2016
HOTMANN, MARKIndividualCORPORATE DIRECTORsince 12/31/2024
JONES, CHARLESIndividualCORPORATE DIRECTORsince 12/31/2021
SHARP, STACYIndividualCORPORATE DIRECTORsince 12/31/2019
WARTES, MICHAELIndividualCORPORATE DIRECTORsince 12/31/2017
YOUNG, MICHAELIndividualCORPORATE DIRECTORsince 12/31/2021
ZIMMER, RICHARDIndividualCORPORATE DIRECTORsince 12/31/2019
RANKIN, RONIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/30/2022
SINGLETON, KATHERINEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/30/2022
STILLMAN, MICHELLEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/30/2022

CMS files one row per role, so the 23 rows in the source record cover these 18 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

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 745022. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-12, 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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