No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

College Street Health Care Center

4150 College St, Beaumont, TX 77707 · Government - Hospital district · 50 certified beds · (409) 842-2244 Medicare & Medicaid certified

Call the home — (409) 842-2244 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0600, F0602) — most recent Jun 20251 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)
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)
  • no federal fines or payment denials on record
Worth asking about
  • it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Jun 2025
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (2/5)
  • its facility-reported quality-measure 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 2 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
4004 College St · (409) 840-4004 · Call to confirm hours
Pharmacy
Cvs0.3 mi
3595 College St · (409) 835-1788 · Call to confirm hours
Grocery
520 S 11th St · (409) 833-2626 · Call to confirm hours
Park
3785 Milam St · (409) 951-6700 · 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 2 of 5
Long-stay residentspeople who live here 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 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 increased25.8%15.8%15.4%worse
Long-stay residents who lose too much weight6.6%3.0%5.4%worse
Long-stay residents with a catheter left in their bladder0.5%0.3%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.9%0.8%2.0%typical for the state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms1.9%2.4%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.0%3.3%3.3%check this — see note marked star below the table
Long-stay residents whose ability to walk worsened25.6%14.0%16.1%worse
Long-stay residents on antianxiety or hypnotic medication29.9%18.0%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers6.1%3.8%4.7%worse
Long-stay residents with worsening bladder/bowel control13.2%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table19.4%9.6%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine92.2%88.0%79.4%better
Long-stay hospitalizations per 1,000 resident days3.262.171.67worse
Long-stay outpatient ER visits per 1,000 resident days2.122.061.80worse

* 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.

41.6% 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 27 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

41.6%U.S. median 51.5%
Got home and stayed home
11.1%U.S. median 10.7%
Went back to hospital
0.62U.S. median 0.31
Therapy hours / resident / day
0.20hours / resident / day
Physical therapy
0.29hours / resident / day
Occupational therapy
0.13hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.62 therapist hours per resident per day in 2026Q1 — more than 89% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 31% 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 SNF41.6%CMS range 25.3–57.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.1%CMS range 7.3–17.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot 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 dischargenot 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 dischargenot 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 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 setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 stay3.3%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 worsened13.3%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 hospitalization8.5%CMS range 4.4–14.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.231.02Oct 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

0.30
RN hours/ resident / day
1.28
LPN hours/ resident / day
1.94
Aide hours/ resident / day
3.52
Total nurse hours/ resident / day
0.30
RN hoursweekends
55.6%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 50 beds and averages 40.6 residents a day — about 81% occupied, or roughly 9 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 3.52 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.30 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.94 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 3.18 hrs/resident/day on weekends vs 3.66 on weekdays — 13% thinner on weekends. RN hours go from 0.30 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 56% 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

6
deficiencies at the latest standard inspection (2025-08-06)
3
at the previous standard inspection (2024-07-17)

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

Inspection deficiencies

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

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

22 citations, most serious first. The 11 most serious are shown; the remaining 11 are one tap away and print in full.

  • Actual harm · G2023-06-14 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents were free from abuse for 1 of 14 residents (Resident #14) reviewed for resident abuse. The facility did not ensure Resident #14 was free from abuse, as a result Resident #14 was physically assaulted by Resident #138 and was injured. This failure could place residents at risk of physical harm, mental anguish, or emotional distress. The noncompliance was identified as PNC. The noncompliance began on 4/9/23 and ended on 4/18/23. The facility had corrected the noncompliance before the survey began. The findings included: 1. Record review of the face sheet, dated 06/14/2023, revealed Resident #14 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of hypertensive heart disease (group of heart conditions caused by high blood pressure), type 2 diabetes mellitus without complications (high blood sugar), and generalized anxiety disorder (condition with exaggerated tension, worrying, and nervousness about daily life…

    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 · Past Non-Compliance
  • Potential for harm · E2025-08-06 · tag F0580 — failed to tell family and doctor about changes — pattern
    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 failed to ensure the physician was consulted regarding a need to alter treatment for 2 of 13 residents reviewed for notification of changes. (Resident #16 and Resident #24) The facility did not consult with Resident #16's physician about the pattern of low blood pressure over consecutive days and of the blood pressure medication being held for 52 of 60 opportunities in July 2025 or 9 of 12 opportunities for August 2025. The facility did not consult with Resident #24's physician about the pattern of low blood pressure over consecutive days and of the blood pressure medication being held for 7 of 31 opportunities in July 2025 or 3 of 6 opportunities for August 2025. This failure could place residents at risk for complications due to delayed or failed physician intervention. Findings included: 1. Record review of the face sheet dated 08/06/25 Resident #16’s indicated Resident #16 was [AGE] year-old female admitted on [DATE] with diagnoses including end stage renal…

    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 · Ecited before2025-08-06 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 7 residents (CR #1 and CR #2) reviewed for pharmacy services. The facility failed to ensure 20 boxes of Fiberone chocolate donuts that expired 06/08/25, (58 days expired) were removed from use. The facility failed to ensure discharged residents' (CR #1 and CR #2) medications were removed from use. This failure could place residents at risk of not receiving medications as ordered by their physicians and exacerbations of their medical conditions.Findings included:During an observation and interview on 08/05/25 at 10:45 a.m. of the facility medication storage room with LVN A, indicated on a shelf there were 20 boxes of Fiberone chocolate donuts (each box had 4 donuts) with a manufacture expiration date of 06/08/25 (expired for 58 days). LVN A said no resident was receiving the Fiberone donuts and eating 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-06 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    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 any drug regimen irregularities were accurately reported by the pharmacist consultant for 2 of 13 residents reviewed for pharmacy services. (Resident #16 and Resident #24) The Pharmacy Consultant failed to thoroughly review the medication regimen and identify possible and/or actual irregularities in the blood pressure and heart rate for Residents #16 and #24. The failure could place residents at risk of receiving inaccurate administration of medications which could result in possible adverse effects or residents not receiving therapeutic benefits of medications. Findings included: 1. Record review of the face sheet dated 08/06/25 Resident #16’s indicated Resident #16 was [AGE] year-old female admitted on [DATE] with diagnoses including end stage renal disease and high blood pressure. Record review of physician orders date July 2025 and August 2025 indicated the orders for Resident #16 included the Coreg 3.125 mg twice a daily for high blood…

    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 · E2025-08-06 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure all drugs and biological were labeled, stored under proper temperature controls and in accordance with currently accepted professional principles for 1 of 1 medication rooms and 1 of 1 medication refrigerators reviewed for storage of medication and biologicals. The facility failed to store medications within recommended temperature range in the medication refrigerator in the medication storage room. The facility failed to ensure that there were not 3-4 inches of ice build-up and no standing water in the medication storage refrigerator. The facility failed to ensure there was no stool specimen comingled with medications and stored in the medication room refrigerator. These failures could place residents at risk of adverse reactions to medications, not receiving therapeutic effects of medication and possibly cross-contamination.Findings included:During an observation and interview on 08/05/25 at 11:00 a.m. of the facility medication storage room with LVN A, it was observed in the medication refrigerator,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-06 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure 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 that the medication error rate was not five percent or greater. The facility had a medication error rate of 10%, based on 3 errors out of 29 opportunities, which involved 1 of 3 residents reviewed (Resident # 18) and 1 of 2 staff (LVN A) reviewed for medication errors. LVN A failed to administer Resident #18's senna (vegetable laxative) 8.6mg, hydromorphone (opioid pain medication used to treat moderate to severe pain) and artificial tears 1 drop to both eyes according to the physician's order. These failures could place residents at risk for decline in health and decreased quality of life. Findings include: Record review of a face sheet dated [DATE] indicated Resident #18 was a [AGE] year-old male admitted on [DATE]. His diagnoses included Parkinsonism (disorder of the central nervous system that affects movement, often including tremors), neurocognitive disorder with Lewy bodies (progressive brain disorder that causes a gradual…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-06 · 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 2 residents (Resident #2) reviewed for infection control. The ADON failed to perform hand hygiene and change gloves while providing wound care to Resident #2's buttock area wound. CNA C failed to perform hand hygiene and change gloves while providing peri-care to Resident #2. These failures could place residents at risk for the spread of infection. Findings include:Record review of Resident 2's face sheet, dated 08/06/25, indicated a [AGE] year-old male who was admitted to the facility on [DATE], with diagnoses of having a pressure ulcer of his left buttock and hypertension (high blood pressure). Record review of Resident #2's admission MDS assessment dated [DATE] indicated Resident #2's skin conditions…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-03 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    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 right to be free from misappropriation of resident property for 1 of 8 residents (Resident #1) reviewed for misappropriation of resident property. The facility failed to ensure LVN A and CNA B did not use Resident #1's debit card to pay their electricity bills. The noncompliance was identified as PNC. The past noncompliance began on 02/27/25 and ended on 04/09/25. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk for misappropriation, exploitation, financial and psychosocial distress. Findings include: Record review of Resident #1's face sheet dated 06/03/25, indicated she was was a [AGE] year old female, admitted on [DATE], and her diagnoses included acute respiratory failure with hypoxia (low levels of oxygen), cognitive communication deficit (trouble with one or more cognitive processes involved in communication such as attention and memory and problems staying on topic), diabetes…

    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 · Past Non-Compliance
  • Potential for harm · Dcited before2025-06-03 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 residents (Resident #2) reviewed for care plans. The facility failed to develop and implement Resident #2's care plan for falls and fall interventions after he fell and sustained a head laceration on 03/22/25. This failure could place residents at risk for injury from falls. Findings included: Record review of Resident #2's face sheet dated 06/02/25 indicated he was a [AGE] year old male admitted on [DATE] and his diagnoses included diabetes (high blood sugar), muscle weakness (lack of muscle strength), unspecified lack of coordination, muscle wasting and atrophy (thinning or loss of muscle mass and strength), cognitive communication…

    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 before2025-06-03 · 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 observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 out of 5 (Resident #3 and Resident #4) residents reviewed for enhanced barrier precautions (EBP) for infection control practices. The ADON failed to follow enhanced barrier precautions during care for Resident #3 who had a Foley catheter and wound. The facility failed to ensure the podiatrist followed enhanced barrier precautions for Resident #4 who had an indwelling medical device (g-tube). The failures could place residents at risk for cross contamination and the spread of infection. The findings included: Record review of Resident #3's admission Record, dated 06/02/25, indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including insomnia, essential hypertension, muscle weakness, and…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-07-17 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for 4 of 14 residents (Residents #10, #20, #21, and #24) and failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and drug records were in order and that an account of all controlled drugs was maintained for 1 of 14 residents (Resident #10) to meet the needs of each resident for reviewed for pharmacy services. LVN A did not prepare medications for Resident #21 per the facility policy. RN D did not flush Resident #10's gastric tube (tube surgically inserted through the wall of the abdomen directly into the stomach) per gravity and did not destroy the used fentanyl (scheduled II controlled medication used for severe pain) patches in a sharps container per policy and with a witness for…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · D2024-07-17 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a significant change MDS assessment within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition a significant change of condition for 1 of 14 residents reviewed for assessments. (Resident #25) The facility failed to complete a Significant Change MDS for Resident #25 within 14 days after the resident was admitted to hospice services. This failure could place residents who experienced a significant change in their condition requiring an MDS assessment at risk of not receiving needed services. Findings Included: Record review of a face sheet dated 07/15/24 indicated Resident #25 was a [AGE] year-old-male with a readmission date of 06/20/24 and an admission date of 09/15/22. Resident #25 was admitted with diagnoses including atherosclerosis (a buildup of fats and other substances in and on the artery walls) and heart failure (a chronic condition in…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-17 · 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 observation, interview 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 of 14 residents reviewed for quality of care. (Resident #85) The facility did not assess or obtain orders for a post-surgical incision to Resident #85's left hip. This failure could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being. Findings included: Record review of physician orders dated July 2024 indicated Resident #85, admitted [DATE], was a [AGE] year-old female with a diagnosis of displaced intertrochanteric closed fracture of the left femur (fracture of the hip that is made up of the thigh bone and the pelvis [socket]. The orders did not indicate the resident had orders to treat the left hip incision. Record review of the clinical record dated 07/14/24…

    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 · E2023-06-14 · 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 safety in the facility's only kitchen. The facility failed to ensure: 1. Food items were dated and labeled. 2. Hair restraints were worn appropriately by dietary staff. 3. The microwave was clean and free of food debris. 4. The juice machine spigot was clean. 5. The ice machine was clean and free from debris. These failures could place residents at risk for foodborne illness. Findings include: 1. During an observation and interview with the Dietary Manager of the kitchen refrigerators on 06/12/2023 starting at 9:03 a.m. revealed a pitcher of a liquid substance identified by the Dietary Manager as grape juice unlabeled and undated; 2 packages of waffles undated; storage container of a liquid substance that the Dietary Manager stated she was unable to identify unlabeled and undated; 2 (20oz) squeeze grape jelly undated; plastic storage bag identified by the Dietary Manager as peaches unlabeled and undated; 1 container…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-06-14 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident's medical record were complete for 4 of 5 residents (Residents #21, #13, #5 and #18) reviewed for medical records. 1. The facility failed to ensure Resident #21's medical record contained evidence of education on the influenza vaccine when the vaccine was administered to the resident. 2.The facility failed to ensure Resident #13's medical record contained evidence of education on the influenza immunization when the vaccine was administered to the resident. 3.The facility failed to ensure Resident #5's medical record contained evidence of education on the influenza vaccine when the vaccine was administered to the resident. 4. The facility failed to ensure Resident #18's medical record contained evidence of education on the influenza immunization when the vaccine was administered to the resident. These failures could place residents at risk for contracting a viral disease that could spread through the facility and cause respiratory…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-14 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure medical records were maintained in accordance with accepted professional standards and practices on each resident and accurately documented for 1 of 14 residents (Resident #28) reviewed for accuracy of medical records. The facility did not ensure Resident #28's OOH-DNR was dated by the physician. This failure could place residents at risk of not receiving care and services to meet their needs. The findings included: Record review of Resident #28's face sheet, dated 06/14/2023, indicated Resident #28 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included diabetes mellitus (high blood sugar), essential hypertension (high blood pressure), and COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #28's physician order summary report, dated 06/14/2023, indicated an active physician's order for code status: DNR with an order date 06/01/2023.…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-14 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review the facility failed to ensure an accurate MDS was completed for 2 of 14 residents (Residents #6 and #37) reviewed for MDS assessment accuracy. 1. The facility failed to accurately code weight loss status for Resident #6 on the MDS assessment. 2. The facility failed to accurately document discharge status for Resident #37 on the MDS assessment. These failures could place residents at risk for not receiving care and services to meet their needs. Findings included: 1. Record review of Resident #6's order summary report, dated 06/14/2023, indicated Resident #6 was a [AGE] year-old female, readmitted to the facility on [DATE] with a diagnosis which included heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), hypertension (high blood pressure), and diabetes mellitus (high blood sugar). Record review of Resident #6's annual MDS, dated [DATE], indicated Resident #6 understood others…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-14 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    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 implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 1 of 14 residents (Resident #18) reviewed for care plans. The facility failed to ensure Resident #18's care plan reflected she had weight loss. This failure could place the residents at increased risk of not having their individual needs met and a decreased quality of life. Findings included: Record review of Resident #18's face sheet, dated 06/14/2023, indicated Resident #18 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included anoxic brain damage (lack of oxygen to the brain), seizures (rapid electrical firing in the brain) and HTN (high blood pressure). Record review of the order summary report dated 06/14/23 indicated Resident #18 was on a pureed diet with regular consistency related to anoxic brain damage. The order summary report…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-14 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    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 develop, review, and revise a comprehensive care plan of each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 14 residents (Resident #7) reviewed for care plans. The facility failed to ensure Resident #7's care plan was updated and revised to reflect she was no longer on transmission-based precautions. This failure could cause the resident to not receive the correct care impacting the patient's health and/or serious illness. Findings included: Record review of Resident #7's face sheet dated 06/14/23 indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #7 had a diagnosis which included type 2 diabetes (blood sugar disorder), cognitive communication deficit (difficulty with thinking and language) and metabolic encephalopathy (brain problem due to chemical imbalance). Record review of Resident #7's Comprehensive MDS dated [DATE]…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    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 necessary services to maintain grooming and personal hygiene were provided for 2 of 3 residents reviewed for ADLs. (Resident #8 and Resident #27) The facility did not ensure Resident #8, and Resident #27 received nail care. These failures could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem. The findings included: 1. Record review of the face sheet, dated 06/14/2023, revealed Resident #8 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of unspecified dementia, without behavioral disturbance (group of symptoms that affects memory, thinking and interferes with daily life), type 2 diabetes mellitus without complications (high blood sugars), unspecified glaucoma (condition where the eye's optic nerve, which provides information to the brain, is damaged with or without raised intraocular pressure). Record review of the 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-14 · tag F0813 — isolated
    Have a policy regarding use and storage of foods brought to residents by family and other visitors.
    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 safe and sanitary storage of resident's food items for 1 of 5 residents reviewed for personal food safety. (Resident #9) The facility did not implement the personal food policy related to personal refrigerators for Resident #9 by failing to check and remove spoiled items that were unlabeled and undated. This failure could place the residents at risk for food borne illnesses. The findings included: Record review of the face sheet, dated 06/14/2023, revealed Resident #9 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of hypertensive heart disease (heart problems caused by high blood pressure), heart failure (progressive heart disease that affects pumping action of the heart muscles), and gastro-esophageal reflux disease without esophagitis (GERD) (acid reflux). Record review of the MDS assessment, dated 05/23/2023, revealed Resident #9 had clear speech and was understood by staff. The MDS revealed…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-14 · 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 ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 residents (Resident #28) reviewed for infection control related to midline dressing changes. LVN G and LVN H failed to maintain aseptic technique (a medical practice and procedure to prevent contamination) during a midline catheter (small tube used to give treatments that is inserted into a vein in your arm and stops in the vein near your armpit) dressing change for Resident #28. This failure could place residents at risk for exposure to blood infection and health complications. The findings included: Record review of the face sheet, dated 06/14/2023, revealed Resident #28 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of sepsis (infection of the blood stream), diabetes mellitus (high blood sugar), and…

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

    Infection Control 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

No federal fines in the current CMS record.

Part of a chain

This home belongs to HEALTH SERVICES MANAGEMENT — 16 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 52.9+1.1 vs chain
Health inspection 4 of 52.9+1.1 vs chain
Staffing 2 of 52.6-0.6 vs chain
Quality measures 2 of 53.5-1.5 vs chain
The other 15 homes this chain runs (chain average 2.9★, 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 / managerTypeRoleShareSince
LIBERTY COUNTY HOSPITAL DISTRICT NO 1Organization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 12/01/2014
HEALTH SERVICES MANAGEMENT, INC.Organization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 12/01/2014
HSMTX/BEAUMONT, LLCOrganization5% OR GREATER MORTGAGE INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2014
STRATTON, CHARLESIndividualCORPORATE DIRECTORsince 12/01/2014
MCMAHON, MICHAELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2014
WHITE, JOSHUAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2014
BAXTER, KEVINIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/06/2025
DESORMEAUX, LORIIndividualADP OF THE SNFsince 12/01/2014

CMS files one row per role, so the 12 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

3 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.

$3.1M
Net patient revenuemost recent cost report
-17.8%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 71%Medicare 8%Other / private 21%

About 71% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$281per resident / day
operating cost
$8,554per month
≈ monthly operating cost
$239per 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 675695. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-06, 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.

What to do next