Avir At Athens
150 Gibson Road, Athens, TX 75751 · For profit - Partnership · 112 certified beds · (903) 677-5864 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- CMS has flagged it for abuse
- it has abuse, neglect, or exploitation citations (F0600, F0609) — most recent May 2026
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- inspectors recorded 3 serious findings 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 (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $243,325 in federal fines (most recent 2024-11-26)
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- nursing-staff turnover (58%) 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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 3 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 | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 13.9% | 15.8% | 15.4% | typical |
| Long-stay residents who lose too much weight | 1.4% | 3.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.7% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.4% | 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 | 1.4% | 3.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 8.5% | 14.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 10.7% | 18.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.0% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 8.9% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.9% | 9.6% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 4.3% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 92.5% | 88.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 33.9% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 20.7% | 12.3% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.53 | 2.17 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.90 | 2.06 | 1.80 | worse |
‡ 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.
59.5% 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 48 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.44 therapist hours per resident per day in 2026Q1 — more than 74% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 5% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 59.5%CMS range 46.4–70.5 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.4%CMS range 8.1–15.8 | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 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 — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 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 | 7.9%CMS range 4.7–12.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.06 | 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 112 beds and averages 77.6 residents a day — about 69% occupied, or roughly 34 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.92 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.24 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.78 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.54 hrs/resident/day on weekends vs 3.07 on weekdays — 17% thinner on weekends. RN hours go from 0.25 to 0.20 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 58% is well above the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
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.
22 citations, most serious first. The 14 most serious are shown; the remaining 8 are one tap away and print in full.
- Immediate jeopardy · Jcited before2024-11-26 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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, record review and interview the facility failed to ensure a resident had the right to be free from abuse for 1 of 7 residents reviewed for abuse (Resident #1). LVN E and CNA D witnessed CNA C abusing Resident #1. CNA C hit Resident #1 and was allowed to remain in the facility for over three hours with access to Resident #1 and other Residents. The noncompliance was identified as PNC (past non-compliance). The IJ (Immediate Jeopardy) began on 4/19/24 and ended 4/19/24. The facility had corrected the noncompliance before the survey began. The facility failures could have caused residents serious physical injury. Findings Included: Record review of Resident #1's face sheet indicated she was an [AGE] year-old female admitted to the facility on [DATE]. She had a diagnosis of Alzheimer's disease (progressive disease that destroys memory), and unsteadiness on feet. Record review of Resident #1's Quarterly MDS dated [DATE] indicated she was severely cognitively impaired with a BIMS score of 5. 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.
- Immediate jeopardy · Jcited before2024-11-26 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the alleagtion involve abuse or result in serious bodily injury, to the Administrator of the facility and to other officials in accordance with State law for 1 of 7 residents reviewed for abuse (Resident #1.) LVN E and CNA D did not immediately report abuse to the Administrator after they witnessed CNA C abusing Resident #1. CNA C hit Resident #1 and was allowed to remain in the facility for over three hours with access to Resident #1 and other Residents. The noncompliance was identified as PNC (past non-compliance). The IJ (Immediate Jeopardy) began on 4/19/24 and ended 4/19/24. The facility had corrected the noncompliance before the survey began. This failure could have caused continued abuse to Resident #1 and possibly other residents. Findings included: 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.
- Immediate jeopardy · J2024-11-26 · 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 interview and record review the facility failed to ensure a resident received adequate supervision and assistive devices to prevent accidents for 1 of 7 residents reviewed for accidents (Resident #2). CNA A failed to ensure two staff members provided a Hoyer lift transfer. A family member assisted with the transfer, the Hoyer lift sling strap was not attached properly, and Resident #2 fell out of the Hoyer lift. The noncompliance was identified as PNC (past non-compliance). The IJ (Immediate Jeopardy) began on 3/3/24 and ended 3/3/24. The facility had corrected the noncompliance before the survey began. This failure could have caused serious injury. Findings included: Record review of Resident #2's face sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were muscle weakness, obesity, and lack of coordination. Record review of Resident #2's admission MDS dated [DATE] indicated the resident had a BIMs score of 13 indicating she was cognitively intact.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · K2023-10-25 · tag F0757 — failed to avoid unnecessary drugs — patternEnsure each resident’s drug regimen must be free from unnecessary 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 interview, and record review the facility failed to ensure the drug regimen was free from unnecessary medication for 1 of 5 (Resident #74) residents reviewed for unnecessary medications. 1. The facility failed to ensure Resident #74 did not receive a medication she was allergic to (ibuprofen) ordered for a swollen right hand on 5/22/23. 2. The facility failed to ensure Resident #74 was not given medications she was allergic to as ordered (ibuprofen 400 mg by mouth 4 times a day for 14 days). Resident #1 received ibuprofen from 05/22/23 to 07/23/23 (63 days). 3. The facility failed to ensure Resident #74's ibuprofen was discontinued after Resident #1 returned from the hospital from an upper GI bleed. Resident #1 received scheduled ibuprofen on 07/26/23 through 07/27/23 (4 doses). An Immediate Jeopardy (IJ) was identified on 10/20/23. While the IJ was removed on 10/21/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate threat due to…
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 before2026-05-31 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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, interviews and record review, the facility failed to ensure residents were free from physical abuse for 1 of 8 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 was free from physical abuse when CNA B slapped Resident #1's arm during patient care on 5/10/26.This failure could place residents at risk for physical abuse, mental abuse, emotional abuse, and harm.Findings included:Record review of an undated Face sheet printed on 5/30/26 indicated Resident #1 was a [AGE] year-old male who admitted on [DATE] with diagnoses including dementia without behavioral disturbance (a clinical presentation where a person experiences progressive decline in cognitive functions (like memory, thinking, or language) that interferes with daily life, but without accompanying psychiatric or behavioral symptoms such as aggression, severe agitation, or delusions), chronic kidney disease (the progressive loss of kidney function over time, impairing the organ's ability to filter…
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 before2026-05-31 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the Administrator of the facility for 1 of 8 (Resident #1) residents reviewed for abuse. The facility failed to ensure CNA C and LVN D immediately reported an allegation of staff-to-resident abuse on 5/10/26 when CNA B slapped Resident #1's arm to the facility Administrator This failure could place residents at risk of injuries, abuse, and/or neglect.Findings included: Record review of an undated Face sheet printed on 5/30/26 indicated Resident #1 was a [AGE] year-old male who admitted on [DATE] with diagnoses including dementia without behavioral disturbance (a clinical presentation where a person experiences progressive decline in cognitive functions (like memory, thinking, or language) that interferes with daily life, but without accompanying…
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 before2026-03-10 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect 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 record reviews and interviews, the facility failed to notify the representative immediately of a significant change in condition and transfer to the hospital for 1 of 5 residents reviewed for notification requirements. The facility failed to notify Resident #1's representative on (1/21/2026) when there was a change in the resident's condition requiring the resident to be sent to the local hospital. This failure could place residents at risk of not having family members or representatives notified of changes in condition and allowing them to participate in care decisions. Resident #1 was a [AGE] year-old female born 11/26/1954 and admitted on [DATE]. According to a face sheet dated 3/10/2026, she had a diagnosis including cerebral infarction due to embolism of left middle cerebral, type 2 diabetes mellitus, primary hypertension, congestive heart, failure chronic kidney disease stage 3, aphasia (nonfluent slow speech with difficulty producing language) following cerebrovascular disease. According to a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-02-18 · tag F0755 — failed to provide safe pharmacy services — patternProvide 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 ensure medications were available and administered for 1 of 6 residents (Resident #87) reviewed for medication administration. The facility failed to ensure that Resident #87's medications Clonazepam (a benzodiazepine medication that produces a calming effect, reducing anxiety) and Hydrocodone-Acetaminophen (an opioid medication that relieves pain) were available for 6 consecutive days following admission. This failure could place residents at an increased risk of and exacerbation of underlying medical conditions, avoidable discomfort, and a decline in physical or psychosocial well-being. A record review of an undated face sheet indicated Resident #87 was a [AGE] year-old female admitted to the facility on [DATE]. She had diagnoses of encephalopathy (a group of conditions that cause brain dysfunction, leading to altered mental states and various neurological symptoms), hypothyroidism (a condition in which the thyroid gland does 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 · E2026-02-18 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were complete and accurately documented for 3 of 5 residents (Residents #53, #59, #73) reviewed for medical records accuracy. The facility failed to ensure Resident #53's physician's orders included an order for oxygen use. The facility failed to ensure Resident #59's physician's orders included an order for a foley catheter. The facility failed to ensure resident #73's physician's orders included orders for diet and dialysis treatments. These failures could place residents at risk for errors in care and treatment. Findings included: 1.Record review of a face sheet dated 02/18/2026 indicated Resident #53 was a [AGE] year-old male who admitted to the facility on [DATE]. He had diagnoses which included tracheostomy status (opening in the neck into the windpipe to facilitate breathing, traumatic hemorrhage of the cerebrum (the rupture of blood vessels…
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 · D2026-02-18 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to develop and implement baseline care plan within 48 hours of admission that includes the instructions needed to provide effective and person-centered care for 1 of 6 residents (Resident #87) reviewed for care plans. The facility failed to ensure that Resident #87 had a completed baseline care plan within 48 hours of admission. This failure could place residents at an increased risk of decline in physical or functional well-being, of not receiving necessary care or services, and of having personalized plans developed/implemented to address their needs. The findings included: A record review of an undated face sheet indicated Resident #87 was a [AGE] year-old female admitted to the facility on [DATE]. She had diagnoses of encephalopathy (a group of conditions that cause brain dysfunction, leading to altered mental states and various neurological symptoms), hypothyroidism (a condition in which the thyroid gland does not produce enough hormones),…
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 · E2024-12-04 · 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 accurate MDS assessments were completed for 6 of 9 residents (Residents #1, #2, #17, #50, #60, and #65) reviewed for accuracy of MDS assessments. The facility failed to ensure Residents #1, #2, #17, #50, #60, and #65's MDS assessment was accurately coded for Preadmission Screening and Resident Review (PASRR). These failures could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings included: 1.A review of Resident #1's face sheet for December 2024 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included traumatic brain injury, anxiety, psychosis, schizophrenia and depressive disorder. A review of Resident #1's PASRR Level 1 screening done 11/07/2022 indicated she was positive for MI/ID/DD. A review of Resident #1's PASRR Evaluation done 11/08/2022 indicated she was negative for ID and negative for DD. The resident 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 before2024-12-04 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect 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 observation, interviews and record reviews, the facility failed to notify the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complications) for 1 of 4 residents (Resident #54) reviewed for change in condition. LVN B failed to notify the physician when she did not administer Resident #54's scheduled insulin dose due to low blood sugar level. This failure could place residents at risk for non-therapeutic effects of the medication and decline in health status. Findings included: A record review of Resident #54's face sheet indicated she was a [AGE] year-old female who admitted to the facility on [DATE]. She had multiple diagnoses which included diabetes mellitus, dysphagia (difficulty swallowing) following a stroke, gastrostomy status (refers to the presence of a surgical opening into the stomach that allows for nutritional…
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 before2024-12-04 · 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 observation, interview and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 3(Resident #22) reviewed for pharmacy services. MA C failed to administer a correct dose of a scheduled medication, lactulose solution (to treat constipation and liver disease) to Resident #22 as ordered by the physician. This failure could place residents at risk for not receiving the intended therapeutic response of prescribed medications which could result in diminished health and well-being. Findings included: A record review of Resident #22's face sheet indicated he was a [AGE] year-old male who admitted to the facility on [DATE]. He had diagnoses which included stroke, slow transit constipation (condition where the large intestine moves waste too slowly, leading to constipation and other issues), and chronic hepatic failure (liver is permanently damaged and can no longer function properly).…
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 · E2023-10-25 · tag F0644 — patternCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review Level 1(PASRR 1) Screening for 3 of 12 residents reviewed for PASRR (Residents #12, 23, and #45). The facility failed to ensure Residents #12, #23, and #45 had accurate PASRR Level 1 Screenings indicating diagnoses of mental illness. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs. Findings included: Resident #12 Record review of Resident 12's PASRR Level 1 Screening completed on 03/27/2023 indicated in section C0100 this resident did not have evidence of having a mental illness. Record review of an undated face sheet indicated Resident #12 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including major depressive disorder. Record review of the Comprehensive (admission) MDS assessment…
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 8 citations
- Potential for harm · Ecited before2023-10-25 · tag F0755 — failed to provide safe pharmacy services — patternProvide 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 ensure pharmaceutical services were provided to meet the needs of 1 of 4 residents reviewed for pharmacy services. (Resident #127). The facility failed to ensure pantoprazole granules DR for oral suspension were administered correctly to Resident #127. This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them correctly as directed by manufacturer's directions. Findings included: Record review of Resident #127's face sheet, dated 10/22/2023, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. She had diagnoses which included gastro-esophageal reflux disease (acid indigestion), congestive heart failure, fractured femur, high blood pressure, dementia, and anxiety. Record review of Resident #127's admission progress notes, dated 10/03/2023, indicated she was alert and oriented to herself only; she had a BIMS (Brief Interview for Mental Status) of 99…
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 · E2023-10-25 · 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, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments and permitted only authorized personnel to have access to 1 of 2 rooms (DON's office) and 1 of 3 medication carts used for storage of medications and other biological chemicals. The facility failed to ensure MA B kept OTC medications secured in the medication cart and unable to be accessed by unauthorized personnel. The facility failed to ensure the DON's office was secured and unable to be accessed by unauthorized personnel. These failures could place residents at risk for misuse of medication and overdose, drug diversions, and adverse reactions to medications. Findings included: During observation of medication administration on 10/23/2023 beginning at 09:10 AM, MA B opened a new bottle containing 100 generic multivitamins, removed 1 (one) tablet from the bottle, put the vitamin tablet in a medicine cup, put the lid on the bottle, and set the bottle on top of the medication cart. MA B obtained…
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 · E2023-10-25 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of disease and infection for infection control and based on observations, interviews, and record reviews, the facility failed to implement infection control practices designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 6 of 7 residents (Resident #'s 6, 27, 32, 46, 68 and 70) reviewed for infection control practices, in that:. *Resident #'s 6, 42, and 68's O2 tubing was not covered and Resident #46's oxygen tubing was not labeled correctly. *Resident #70's Nebulizer tubing was not covered. *Resident #32's CPAP tubing was dirty and not covered; and *Facility staff did not disinfect the glucometer properly before and after it was used on Resident #27. This failure placed residents' risk for exposure to possible transmission of communicable diseases…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-25 · 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 the Pre-admission Screening and Resident Review (PASRR) Level I assessment was completed prior to admission. For 1 of 12 residents (Residents #60) reviewed for PASRR Level I screenings. The facility failed to have a level 1 PASRR assessment for Resident #60 available/documented. This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs. Findings included: Record review of Resident #60's face sheet, date 09/20/23, indicated she was an [AGE] year-old female, admitted to the facility on [DATE]. Resident #60 diagnoses included non-Alzheimer's dementia unspecified severity, with other behavioral disturbance on admission, psychotic disorder with delusions due to known physiological condition, major depressive disorder, recurrent severe without psychotic features, anxiety disorder, and Parkinson's disease. Record review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-25 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a medication error rate less that 5 percent. There were 3 errors out of 34 opportunities, resulting in an 8 percent medication error rate involving 1 of 3 residents (Resident #13). MA B failed to administer 2 scheduled medications, spironolactone (to treat excess fluid in the tissues) and vitamin D3 (to treat vitamin deficiency), to Resident #13 as ordered by the physician. MA B failed to follow physician's orders regarding specific instructions for the administration of polyethylene glycol 3350 (for treatment of constipation). These failures could place the resident at risk of not receiving the therapeutic effect of the mediations and could result in a decline health status. Findings included: Record review of an undated face sheet indicated Resident #13 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including hypertension (elevated/high blood pressure), chronic peripheral venous insufficiency…
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 · D2023-10-25 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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 significant medication errors for 1 of 3 residents (Resident #13) reviewed for medication administration accuracy. MA B failed to administer a scheduled medication, spironolactone (used to treat high blood pressure and excess fluid in the tissues, to Resident #13 as ordered by the physician. This failure could place the resident at risk of not receiving the therapeutic effects of the mediation and could result in a decline health status. Findings included: Record review of an undated face sheet indicated Resident #13 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including hypertension (elevated/high blood pressure), chronic peripheral venous insufficiency (improper functioning of the valves in the leg causing swelling), and acute pulmonary edema (excess fluid in the lungs). Record review of Resident #13's Quarterly MDS assessment dated [DATE] indicated her cognition to be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-08-28 · tag F0755 — failed to provide safe pharmacy services — patternProvide 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 assured the accurate administration of all drugs and biologicals to meet the needs of each resident for two of six residents (Resident #1 and Resident #2) reviewed for medications. The facility failed to ensure all medications were administered according to facility procedure when nursing staff failed to document the administration of medications within the one-hour window according to facility policy. This failure could place residents at risk for not receiving the therapeutic benefits from medications. Findings included: Resident #1 Review of a face sheet showed Resident #1 was an [AGE] year-old female admitted on [DATE] with diagnoses of Essential (Primary) Hypertension (High Blood Pressure), Epilepsy (a condition which could cause seizures), Transient Cerebral ischemic attach (Stroke), and Atherosclerotic heart disease of native coronary artery without angina pectoris (A buildup…
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.
- No harm found · C2023-10-25 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to post the daily nurse staffing data at the beginning of each shift in a prominent place, readily accessible to residents and visitors that included the facility name; the total number of hours worked per shift by the registered nurses, the licensed vocational nurses, and the certified nurse aides directly responsible for resident care for the facility for 2 of 3 days reviewed for staffing postings (10/22/23 - 10/23/23) and did not maintain the posted daily nurse staffing data for a minimum of 18 months. The facility did not post the required staffing with hours worked daily for the public and residents and did not maintain the staffing for a minimum of 18 months. This failure could place the census of 76 residents, families, and visitors at risk of not having the daily nurse staffing data. Findings include: During a daily observation on 10/22/2023 to 10/23/2023 beginning at 9:30 a.m. each day, revealed no staffing posting was posted in the lobby, halls to resident's rooms, or at the nurse station with total…
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
$243,325 in federal fines across 4 penalties.
- $8,400 — penalty dated 2024-11-26
- $8,400 — penalty dated 2024-11-26
- $12,844 — penalty dated 2024-11-26
- $213,681 — penalty dated 2023-10-25
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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| FANNIN COUNTY HOSPITAL AUTHORITY | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 03/31/2017 |
| SANDERSON, CLARK | Individual | CORPORATE OFFICER | — | since 08/01/2025 |
| 150 GIBSON RD OPCO, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 08/01/2025 |
| BATSON, JUSTIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/21/2022 |
| EDWARDS, JONATHAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2023 |
| FREUND, NOCHUM | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 08/01/2025 |
| TRAVITSKY, AARON | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 08/01/2025 |
| DAGAN, AMITAI | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 11/11/2025 |
| GOLDBERGER, ABRAHAM | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 11/11/2025 |
| GOLDBERGER, FAIGY | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 11/11/2025 |
| 150 GIBSON RD PROPERTY OWNER, LLC | Organization | ADP OF THE SNF | — | since 08/01/2025 |
| WELLTOWER NNN GROUP, LLC | Organization | ADP OF THE SNF | — | since 08/01/2025 |
| WELLTOWER OP, LLC | Organization | ADP OF THE SNF | — | since 08/01/2025 |
CMS files one row per role, so the 15 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.
5 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in TX
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 455834. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-18, 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.