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Will-O-Bell

412 N. Dalton, Bartlett, TX 76511 · Government - Hospital district · 90 certified beds · (254) 527-3371 Medicare & Medicaid certified

Call the home — (254) 527-3371 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0607, F0609) — most recent Feb 20243 actual-harm citations$8,279 in federal fines
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
Worth asking about
  • it has abuse, neglect, or exploitation citations (F0607, F0609) — most recent Feb 2024
  • it has 3 actual-harm citations
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,279 in federal fines (most recent 2023-10-09)
  • its payroll-based staffing rating is low (2/5)

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 4 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
213 Millcreek Dr Ste 190 · (254) 947-7900 · Call to confirm hours
Pharmacy
305 Limestone Ter · (512) 746-0901 · Call to confirm hours
Grocery
212 E Bell St · (254) 527-3356 · Call to confirm hours
Park
300 E Travis St · (254) 657-2523 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 3 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
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 increased5.0%15.8%15.4%better
Long-stay residents who lose too much weight3.6%3.0%5.4%better
Long-stay residents with a catheter left in their bladder0.3%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.7%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.0%2.4%6.5%check this — see note marked star 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 injury5.8%3.3%3.3%worse
Long-stay residents whose ability to walk worsened5.4%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication18.2%18.0%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers4.0%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control10.8%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table7.5%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication2.8%1.5%1.4%worse
Short-stay residents rehospitalized after admission15.3%25.7%22.6%better
Short-stay residents with an outpatient ER visit10.8%12.3%12.0%better
Long-stay hospitalizations per 1,000 resident days2.422.171.67worse
Long-stay outpatient ER visits per 1,000 resident days1.132.061.80better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

9.8%U.S. median 10.7%
Went back to hospital
25.0%U.S. median 56.6%
Met the expected recovery
0.25U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.07hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 25.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 24 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.25 therapist hours per resident per day in 2026Q1 — more than 35% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 9% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.8%CMS range 6.2–15.910.7%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 discharge25.0%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 discharge20.8%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 discharge29.2%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 identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or 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 hospitalization7.7%CMS range 4.2–15.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.991.02Oct 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

0.23
RN hours/ resident / day
0.74
LPN hours/ resident / day
2.32
Aide hours/ resident / day
3.29
Total nurse hours/ resident / day
0.13
RN hoursweekends
38.7%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 90 beds and averages 73.1 residents a day — about 81% occupied, or roughly 17 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.29 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.23 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.32 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 2.77 hrs/resident/day on weekends vs 3.50 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.26 to 0.13 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 39% is about the same as 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

3
deficiencies at the latest standard inspection (2026-05-14)
4
at the previous standard inspection (2025-03-27)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

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.

29 citations, most serious first. The 13 most serious are shown; the remaining 16 are one tap away and print in full.

  • Actual harm · G2023-10-09 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately 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 interview and record review, the facility nursing staff failed to immediately notify the physician of a significant change in the resident's physical status for 1 of 2 residents reviewed for an unknown injury (Resident #2) LVN B and RN A failed to immediately notify Residents' Physician when a large bruise was discovered on his ankle, which was discovered to be a fracture. This failure may have resulted in Resident #2 experiencing pain from a fracture for 4-5 days. Findings included: Review of the face sheet for Resident #2's revealed he was a [AGE] year-old male initially admitted on [DATE], latest readmission on [DATE]. Resident #2 diagnoses include osteoporosis (fragile bones), repeated falls, cerebral palsy (impaired muscle coordination), and cognitive communication deficit. Review of the Annual Minimum Data Set (MDS) for Resident #2's, dated 7/12/23, revealed a Brief Interview for Mental Status (BIMS) score was not assessed due to Resident #2 being rarely/never understood. Review of Resident #2'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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2023-10-09 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    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 staff failed to report to the administrator and/or designee, physician, and failed to investigate an injury of unknown source for 1 of 2 (Resident #2) reviewed for incident reporting. LVN B and RN A failed to reported an injury of unknown origins on Resident #2 to the Nurse Practitioner or Doctor, to receive orders of care. This failure could place residents at risk of a delay in needed treatment. Findings included: Review of the face sheet for Resident #2's revealed he was a [AGE] year-old male initially admitted on [DATE], latest readmission on [DATE]. Resident #2 diagnoses include osteoporosis (fragile bones), repeated falls, cerebral palsy (impaired muscle coordination), and cognitive communication deficit. Review of the Annual Minimum Data Set (MDS) for Resident #2's, dated 7/12/23, revealed a Brief Interview for Mental Status (BIMS) score was not assessed due to Resident #2 being rarely/never understood. Review of Resident #2's Care Plan, initiated…

    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
  • Actual harm · Gcited before2023-10-09 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to immediately, or within 2 hours, report injuries of unknown source to the administrator and/or designee and to other officials for 1 of 2 residents reviewed for an injury of unknown origins (Resident #2) LVN B and RN A did not report an injury of unknown origins on Resident #2 to the Nurse Practitioner or Doctor, to receive orders of care. This failure could place residents at risk of a delay in needed treatment. Findings included: Review of the face sheet for Resident #2's revealed he was a [AGE] year-old male initially admitted on [DATE], latest readmission on [DATE]. Resident #2 diagnoses include osteoporosis (fragile bones), repeated falls, cerebral palsy (impaired muscle coordination), and cognitive communication deficit. Review of the Annual Minimum Data Set (MDS) for Resident #2's, dated 7/12/23, revealed a Brief Interview for Mental Status (BIMS) score was not assessed due to Resident #2 being rarely/never understood. Review of Resident #2'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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-14 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to conduct a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 1 of 6 residents (Resident #39) reviewed for comprehensive assessments. The facility failed to complete an accurate comprehensive assessment for Resident #39. This failure could place residents at risk of not having their care and treatment needs assessed to ensure necessary care and services were provided.The findings include: Record review of Resident #39's face sheet, dated 05/14/26, documented a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #39 had diagnoses which included: congestive heart failure (a serious condition that occurs when the heart can't pump enough blood to meet the body's needs), Alzheimer's disease (a neurodegenerative disease that usually starts slowly and progressively worsens), major depressive disorder (a mental health disorder characterized by persistently depressed mood…

    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 before2026-05-14 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #39) of 6 residents reviewed for quality of care. The facility failed to ensure Resident #39 had her gauze roll placed inside her left hand on 05/13/26 as directed by physician orders. These failures could place residents at risk of not receiving necessary medical care, pain, injury, infection, and hospitalization.Findings included: Record review of Resident #39's face sheet, dated 05/14/26, documented a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #39 had diagnoses which included: congestive heart failure (a serious condition that occurs when the heart can't pump enough blood to meet the body's needs), Alzheimer's disease (a neurodegenerative disease that usually starts slowly and progressively worsens), major…

    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 before2026-05-14 · 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 of 5 residents (Resident #3) reviewed for infection control. Resident #3 had a Stage 3 Pressure Ulcer to the Left buttock and the facility failed to place him on Enhanced Barrier Precautions.This deficient practice could increase the risk of the spread of infection to other residents.Record review of Resident #3's undated face sheet revealed Resident #3 was a [AGE] year-old male admitted on [DATE] with Encephalopathy, (any disease or damage that alters the brain's structure or function), Muscle wasting and atrophy (the shrinking and loss of muscle mass) and Polyosteoarthritis (a degenerative joint disease characterized by the breakdown of cartilage and bone in five or more joints simultaneously. It causes chronic pain,…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-03 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control 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 6 residents (Resident #1) reviewed for infection control.CNA A failed to properly dispose of Resident #1's soiled brief after incontinent are. CNA A failed to change gloves and perform hand hygiene after handling soiled brief.This failure could place residents at risk for infection and hospitalization. Findings include: Record review of Resident #1’s, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included dementia (a general term for a decline in cognitive function that interferes with daily life) in other disease classified elsewhere, severe, with psychotic disturbance and agitation, muscle weakness, major depressive disorder (is a mental health…

    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 · Ecited before2025-03-27 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined the facility failed to ensure drugs and biological's were stored under proper temperature in the Front Medication Room and the Back Medication Room reviewed for medication storage. The facility's failures could place residents receiving medication at risk for lack of drug efficacy. Findings included: During an observation on 03/26/2025 at 09:55 AM of the back medication room revealed that the refrigerator temperature log for the medications was out of range 25 of 26 days of March 2025. The log reflected the temperatures ranged from 28 degrees Fahrenheit to 32 degrees Fahrenheit. On 03/26/2025 the temperature was observed in the fridge at 28 degrees when visually checked. At the time of the observation, the fridge contained insulin pens. During an observation on 03/26/2025 at 11:55 AM of the front medication room revealed that the refrigerator temperature log for the medications was out of range 24 of 24 days of March 2025. The log reflected the temperatures ranged from 28 degrees Fahrenheit to 31 degrees…

    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 before2025-03-27 · 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, interviews, and record review, the facility failed to store, prepare, distribute, and serve food following professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: - Food items were not labeled and/or dated. - Moldy and rotten food was present during inspection of the walk-in refrigerator. These failures could place all residents who received meals from the main kitchen at risk for food-borne illness. Findings include: Observation on 3/25/2025 at 9:15 am of the walk-in refrigerator reflected the following: - Potatoes that were dated 3-9-25 had green sprouts growing from the potato. - The lunch meat dated 3-8-25 was expired. - Diced chicken was dated 3-24-25 with no discard date. - 15 Sandwiches dated 3-25-25 had no discard date. - Ranch dressing was not in the original container, dated 3-8-25, with no discard date. - Grated cheese was not in the original container, dated 3-21-25, with no discard date. - Grated cheese was not in the original container, dated 3-21-2028, with no discard date. - Tomato soup was 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-27 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to submit a complete and accurate request for nursing facility specialized services in the LTC Online Portal within 20 business days after the date of the Interdisciplinary Team meeting for one of one resident reviewed. The facility failed to submit a NFSS form request by the specific deadline for Resident #2 for a pressure reducing mattress and a motorized wheelchair. This failure could place residents at risk of not receiving or benefiting from specialized equipment they may require. Findings included: Record review of Resident #2's Face Sheet reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Muscle weakness (generalized), Muscle wasting and Atrophy, and Unsteadiness on feet. Record review of the MDS dated [DATE] revealed that Resident #2 was PASARR positive, and her Cognitive status was rated with a BIMS of 2. The MDS also revealed recommendation for the resident to be provided with a pressure…

    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 · D2025-03-27 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate PASARR for 1 of 2 residents (Residents #38) reviewed for PASARR Level 1 screenings. The facility failed to notify the local authority of the PASARR I screen for Residents #38. This failure could affect residents with mental illness placing them at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings included: Record review of a Face Sheet dated 03/25/25 for Resident #38 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy); anoxic brain damage non else classified (a catastrophic and potentially fatal injury characterized by the brain's complete deprivation of oxygen. It distinguishes from hypoxic…

    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 before2024-08-05 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for two (Resident #1 and Resident #2) of four residents reviewed for quality of care. The facility failed to: - Ensure Resident #1 was not sitting in his bed with linens covered in feces and his pants saturated with urine. The staff failed to complete accurate skin assessments to be able to provide appropriate treatment to MASD on his buttocks. - Ensure Resident #2 was getting barrier cream applied to a rash on her buttocks and failed to complete accurate skin assessments. These failures placed residents at risk of improper wound management, the development of new pressure injuries, deterioration in existing pressure injuries, infection, and a decreased quality of life. Findings included: Resident #1 Review of resident #1's face sheet dated 08/01/24 reflected an…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-23 · 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 two (Resident #1 and Resident #2) of four residents reviewed for medications. The facility failed to ensure Resident #1 was discharged home without two of Resident #2's medications (Trazadone and Tegretol). This deficiency put residents at risk of consuming unprescribed medications, harm, and hospitalization. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including chronic myelomonocytic leukemia (cancer of the blood-forming cells of the bone marrow), acute pulmonary edema (buildup of fluid in the lungs), and hypertension (high blood pressure). Review of Resident #1's quarterly MDS assessment, dated 01/24/24, reflected a BIMS of 9,…

    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
Show the remaining 16 citations
  • Potential for harm · E2024-02-09 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 3 of 5 residents (Resident #7, #46, and #13) reviewed for indwelling urinary catheter care, in that: 1. Resident #7's indwelling urinary catheter drainage bag was on the floor. 2. Resident #46's indwelling urinary catheter drainage bag was on the floor. 3. Resident #13's indwelling urinary catheter drainage bag was on the floor. These failures could place the residents with indwelling urinary catheter devices at risk for the development of new or worsening urinary tract infections. The findings included: 1. Record review of Resident #7's face sheet, dated 2/9/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included urinary tract infection, abnormalities of gait and mobility, hydronephrosis (condition characterized by…

    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 · E2024-02-09 · tag F0802 — failed to prepare enough nourishing food — pattern
    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 4 of 5 of the food and nutrition service staff reviewed for competency training in that: The facility did not ensure the DM, [NAME] W, [NAME] X, DA Y or DA Z had current food handlers training. The DM's food handler's certificate had an expiration date of 10/12/2023 with a start date of 05/21/2007. Cook W's food handler's certificate had an expiration date of 10/13/2023 with at start date of 06/17/2013. Cook X's food handler's certificate had an expiration date of 10/14/2023 with a start date of 08/17/2007. DA Z's food handler's certificate had an expiration date of 10/15/2023 with a date of 10/27/2008. The deficient practice could place residents who consumed food prepared from the kitchen at-risk of foodborne illness or nutritional deficiencies. The finding included: Interview on 02/08/2024 at 12:05 p.m. with the DM, the DM stated all of the kitchen's staff training was expired, their training…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-02-09 · 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, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen areas in that: There were items in the kitchen that were not dated, not labeled with a date, not labeled with a name, ingredients or contents of packaging, and damaged kitchen spatulas. In addition there were only unpasteurized eggs in the kitchen that had been reportedly served with runny middles to residents. A cook failed to ensure eggs served soft fried with runny middle were pasteurized for 2 residents. These failures could place residents at risk for foodborne illness. The findings included: Observation in the kitchen on 02/06/2024 at 9:26 a.m. revealed: One large bag of cheese cubes opened exposing the contents of the bag to other odors in the refrigerator. One large approximately 5-gallon container of a white substance identified by [NAME] X as thickener with no label or date and opened, in the kitchen under a preparation table. One large bag of a substance later identified…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-02-09 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 8 residents (Resident #3, #30 and #57) reviewed for infection control practices, in that: 1. LVN D did not utilize appropriate hand hygiene during the medication pass to Resident #3 2. Med Aide T did not sanitize the blood pressure cuff used between Resident #30 and Resident #57 These failures could place residents at risk of infection, transmission of communicable diseases and a decline in health. The findings included: 1. Record review of Resident #3's face sheet, dated 2/8/24 revealed an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included type 2 diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy),…

    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 · E2024-02-09 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public for 2 of 4 Halls (Hall #2 and Hall #3) reviewed for environment in that: 1. The bedroom door to Resident room [ROOM NUMBER] on Hall #2 had splintered edges and had several pieces of wood missing and the bedroom door to Resident room [ROOM NUMBER] on Hall #2 had splintered edges and was partially covered in black duct tape. 2. The bedroom door to Resident room [ROOM NUMBER] on Hall #3 had splintered edges and had several pieces of wood missing. The bedroom door to Resident room [ROOM NUMBER] on Hall #3 had splintered edges and had several pieces of wood missing. The bedroom door to Resident room [ROOM NUMBER] on Hall #3 had splintered edges and was partially covered in black duct tape. The bedroom door to Resident room [ROOM NUMBER] on Hall #3 had splintered edges and was partially covered in black duct tape. This deficient practice could place residents 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-09 · tag F0941 — pattern
    Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to include effective communications as mandatory training for 14 of 14 employees (CNA A, LVN B, LVN D, CNA K, CNA L, CNA M, MA N, CNA O, CNA P, CNA Q, LVN R, LVN S, FSS, and AD). The facility failed to provide CNA A, LVN B, LVN D, CNA K, CNA L, CNA M, MA N, CNA O, CNA P, CNA Q, LVN R, LVN S, FSS, and AD with effective communications as mandatory training. This failure could place residents at risk of being cared for by untrained staff. The findings included: Review of CNA A's personnel record had a hire date of 09/27/23, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of LVN B's personnel record had a hire date of 08/24/22, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training. Review of LVN D's personnel record had a hire date of 09/29/22, with annual training in-services provided by the facility that did not include evidence of effective…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-09 · tag F0942 — pattern
    Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide required education on the rights of the resident and the responsibilities of a facility to properly care for its residents for 7 of 14 employees (CNA A, LVN B, CNA L, CNA O, CNA Q, LVN R and AD). The facility failed to ensure education on the rights of the resident and the responsibilities of a facility to properly care for its residents was provided to CNA A, LVN B, CNA L, CNA O, CNA Q, LVN R and AD. This failure could place residents at risk of being cared for by untrained staff. The findings included: Review of CNA A's personnel record had a hire date of 09/27/23, with annual training in-services provided by the facility that did not include evidence of resident rights training. Review of LVN B's personnel record had a hire date of 08/24/22, with annual training in-services provided by the facility that did not include evidence of resident rights training. Review of CNA L's personnel record had a hire date of 03/14/19, with annual training in-services provided by the facility that did not include evidence 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 · E2024-02-09 · tag F0943 — pattern
    Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, and record review, the facility failed to provide resident abuse prevention training to 4 of 18 staff reviewed including CNA K, CNA L, CNA O, and CNA Q. The facility failed to ensure that 4 of 18 staff reviewed had completed their mandatory abuse annual training. This failure could place residents at risk of being cared for by untrained staff. The findings included: Review of CNA K's personnel record had a hire date of 04/24/14, with annual training in-services provided by the facility that did not include evidence of abuse prevention mandatory training. Review of CNA L's personnel record had a hire date of 03/14/19, with annual training in-services provided by the facility that did not include evidence of abuse prevention mandatory training. Review of CNA O's personnel record had a hire date of 11/30/20, with annual training in-services provided by the facility that did not include evidence of abuse prevention mandatory training. Review of CNA Q's personnel record had a hire date of 04/08/22, with annual training in-services provided by the facility that did 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-09 · tag F0944 — pattern
    Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record reviews, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program for 14 of 14 employees (CNA A, LVN B, LVN D, CNA K, CNA L, CNA M, MA N, CNA O, CNA P, CNA Q, LVN R, LVN S, FSS, and AD). The facility failed to ensure that quality assurance and performance improvement training was provided to CNA A, LVN B, LVN D, CNA K, CNA L, CNA M, MA N, CNA O, CNA P, CNA Q, LVN R, LVN S, FSS, and AD. This deficient practice could place residents at risk for not receiving safe and appropriate care by adequately informed staff regarding goals for care as identified by the QAPI committee and could result in a decline in health and well-being. The findings included: Review of CNA A's personnel record had a hire date of 09/27/23, with annual training in-services provided by the facility that did not include evidence of QAPI training. Review of LVN B's personnel record had a hire date of 08/24/22, with annual training in-services provided by 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-09 · tag F0945 — failed to train staff on abuse prevention — pattern
    Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide the mandatory training on standards, policies, and procedures for an infection prevention and control program for 9 of 14 staff (CNA A, LVN B, LVN D, CNA K, CNA L, MA N, CNA O, LVN S and AD) reviewed for training, in that: The facility failed to ensure infection prevention and control training was provided to CNA A, LVN B, LVN D, CNA K, CNA L, MA N, CNA O, LVN S and AD. This failure could place residents at risk of illness due to lack of staff training. The findings included: Review of CNA A's personnel record had a hire date of 09/27/23, with annual training in-services provided by the facility that did not include evidence of infection prevention and control training. Review of LVN B's personnel record had a hire date of 08/24/22, with annual training in-services provided by the facility that did not include evidence of infection prevention and control training. Review of LVN D's personnel record had a hire date of 09/29/22, with annual training in-services provided by the facility that did not include evidence…

    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 · E2024-02-09 · tag F0946 — pattern
    Provide training in compliance and ethics.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to communicate the compliance and ethics program's standards, policies and procedures through a training program or other practical manner which explains the requirements for 8 of 14 employees (CNA A, LVN B, CNA L, CNA O, CNA Q, LVN R, LVN S and AD) reviewed for training, in that: The facility failed to ensure that compliance and ethics training was provided to CNA A, LVN B, CNA L, CNA O, CNA Q, LVN R, LVN S and AD. This failure could place residents at risk for improper care due to a lack of training. The findings included: Review of LVN B's personnel record had a hire date of 08/24/22, with annual training in-services provided by the facility that did not include evidence of compliance and ethics training. Review of CNA L's personnel record had a hire date of 03/14/19, with annual training in-services provided by the facility that did not include evidence of compliance and ethics training. Review of CNA O's personnel record had a hire date of 11/30/20, with annual training in-services provided by the facility that did 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-09 · tag F0947 — failed to train nurse aides adequately — pattern
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to maintain the required minimum of 12 hours annual in-service records for 6 out of 7 CNAs employed for longer than one year reviewed for training (CNA K, CNA L, MA N, CNA O, CNA P and CNA Q). The facility failed to provide CNA K, CNA L, CNA M, MA N, CNA O, CNA P and CNA Q with 12 hours of in-service training per year. This failure could place residents at risk of being care for by untrained staff. The findings included: During the record review and interview with HR personnel on 02/09/24 at 4:30 pm, HR presented a spreadsheet with 22 inservices conducted over the past year forming columns at the top and a list of employees, forming the rows, listed on the first column. An X mark was placed in the column underneath each inservice that an employee attended. HR stated the ADM and DON presented various topics they felt were needed for the facility. HR stated that none of the CNAs had attended the required 12 hours of inservices and that many of the required training topics were not provided to staff. The training that 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-09 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation were reported immediately, but no later than 2 hours after the allegation was made to the State Survey Agency for 1 of 10 residents (Resident #35) reviewed for abuse and neglect. The facility did not report to the State Survey Agency (HHSC) an incident in which Resident #36 was inappropriately touching Resident #35. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm. The findings included: 1. Record review of Resident #35's face sheet, dated 2/7/24 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia, intellectual disabilities, need for assistance with personal care, anxiety disorder (a normal reaction to stress in an intense, excessive, and persistent worry and fear about everyday situations), impulse…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-09 · 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, interviews, and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals, and preferences for 1 of 3 residents (Resident #17) reviewed for oxygen therapy in that: Resident #17's oxygen concentrator filter was covered in a thick white substance. This failure could affect residents who received respiratory therapy and put them at risk for inadequate or inappropriate amounts of oxygen delivery. The findings included: Record review of Resident #17's face sheet, dated 2/8/24 revealed a [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included hypertension (high blood pressure), presence of cardiac pacemaker, heart failure, history of pulmonary embolism (condition in which one or more arteries in the lungs become blocked…

    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 before2024-02-09 · 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 2 of 2 Residents (Resident #3 and #31) reviewed for medication administration in that: LVN D administered insulin to Residents #3 and #31 without priming the insulin pen prior to injection. These deficient practices could affect residents who received medication and place them at risk of not receiving the appropriate amount of medication and could result in an adverse reaction or a decline in health. The findings included: 1. Record review of Resident #3's face sheet, dated 2/8/24 revealed an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included type 2 diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy), chronic kidney disease state 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-09 · 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 the facility failed to ensure the drugs and biologicals used in the facility must be labeled and stored in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions and the expiration date when applicable for 1 of 5 medication carts, (Treatment Cart), and in 1 of 6 resident rooms ( Resident #27's room) in that: 1. The facility failed to ensure the Treatment Cart was not left unattended and unlocked. 2. The facility failed to ensure a container of refresh eyedrops and an albuterol inhaler were stored properly in the facility. This deficient practice could affect residents who receive medications for treatments and could result in less potent or an adverse effects and drug diversion. The findings included: 1. Observation on 2/8/24 at 9:34 p.m. revealed the Treatment Cart was left unattended and unlocked on the 100 Hall next to room [ROOM NUMBER] and facing the hallway. During an interview on…

    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

“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

$8,279 in federal fines across 1 penalty.

  • $8,279 — penalty dated 2023-10-09

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

Part of a chain

This home belongs to CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1 — 7 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 53.0+1.0 vs chain
Health inspection 4 of 53.2+0.8 vs chain
Staffing 2 of 52.3-0.3 vs chain
Quality measures 4 of 53.0+1.0 vs chain
The other 6 homes this chain runs (chain average 3.0★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleSince
BRANT, PENNYIndividualW-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROLsince 05/01/2021
BROWN, GERALDINEIndividualCORPORATE DIRECTORsince 01/01/2024
COOPER, KIMBERLYIndividualCORPORATE DIRECTORsince 01/29/2024
EMMONS, MICHAELIndividualCORPORATE DIRECTORsince 01/01/2024
LEGG, STEPHENIndividualCORPORATE DIRECTORsince 01/01/2024
NEWTON, ELIZABETHIndividualCORPORATE DIRECTORsince 02/22/2024
TINNERMAN, LINDAIndividualCORPORATE DIRECTORsince 01/01/2024
TURNER, LESLIEIndividualCORPORATE DIRECTORsince 01/01/2024
CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO. 1OrganizationOPERATIONAL/MANAGERIAL CONTROLsince 05/01/2021
WOB FACILITY MANAGEMENT, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 05/01/2021
GOODNIGHT, LARRYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2024
SMALLEY, JERRYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2024
STEGLICH, TIMOTHYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2024
VOIGHT, JOHNIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2024
WHITE, LINDAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2024

CMS files one row per role, so the 16 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$5.6M
Net patient revenuemost recent cost report
-0.8%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 3%Medicare 57%Other / private 40%

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

$229per resident / day
operating cost
$6,971per month
≈ monthly operating cost
$227per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in TX

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.

Typical monthly cost in Texas
$5,627/mo
Nursing home (semi-private)
$7,604/mo
Nursing home (private)
$5,666/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 676026. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-14, 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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