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Forum Parkway Health & Rehabilitation

2112 Forum Parkway, Bedford, TX 76021 · For profit - Corporation · 139 certified beds · (817) 799-4600 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 immediate-jeopardy citation$19,083 in federal fines
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $19,083 in federal fines (most recent 2024-09-19)

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.

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2213 Martin Dr · (817) 876-6113 · Call to confirm hours
Pharmacy
Pharmone0.6 mi
2101 Westpark Ct # 135 · (469) 809-8112 · Call to confirm hours
Grocery
ISOGE0.5 mi
124 Wilshire Dr · (469) 798-4468 · Call to confirm hours
Park
315 Sierra Dr · (817) 685-1429 · Typically dawn to dusk
Place of worship
2000 Forum Pkwy · (972) 313-7133

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 3 to 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased6.9%15.8%15.4%better
Long-stay residents who lose too much weight1.5%3.0%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%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 injury2.6%3.3%3.3%better
Long-stay residents whose ability to walk worsened1.9%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication15.5%18.0%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers1.3%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control9.9%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table6.8%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.8%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine99.3%88.0%79.4%better
Short-stay residents rehospitalized after admission21.4%25.7%22.6%typical
Short-stay residents with an outpatient ER visit15.2%12.3%12.0%worse

* 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.

59.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 235 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

59.4%U.S. median 51.5%
Got home and stayed home
11.9%U.S. median 10.7%
Went back to hospital
56.2%U.S. median 56.6%
Met the expected recovery
0.39U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.18hours / resident / day
Occupational therapy
0.10hours / resident / day
Speech therapy

Met the expected recovery: 56.2% 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 64 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 0.39 therapist hours per resident per day in 2026Q1 — more than 67% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% 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 SNF59.4%CMS range 50.8–66.151.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.9%CMS range 9.5–14.610.7%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 discharge56.2%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 discharge59.4%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 discharge34.4%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified96.7%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 setting94.1%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 discharge92.3%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF 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 worsened5.4%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 hospitalization7.5%CMS range 5.0–11.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.021.02Oct 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

0.71
RN hours/ resident / day
0.78
LPN hours/ resident / day
2.22
Aide hours/ resident / day
3.71
Total nurse hours/ resident / day
0.76
RN hoursweekends
49.1%
Total nursing turnover
43.8%
RN turnover

How full it usually is: this home is certified for 139 beds and averages 95.3 residents a day — about 69% occupied, or roughly 44 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.71 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.71 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.22 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 3.42 hrs/resident/day on weekends vs 3.83 on weekdays — 11% thinner on weekends. RN hours go from 0.69 to 0.76 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 49% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

2
deficiencies at the latest standard inspection (2026-03-19)
8
at the previous standard inspection (2025-01-13)

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.

24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.

  • Immediate jeopardy · K2024-09-19 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for 1 of 2 residents (Resident # 1) reviewed for quality of care. The facility did not prevent the development of one facility-acquired Stage IV pressure injury on the right calf for Resident #1. An Immediate Jeopardy (IJ) was identified on 09/18/2024. The IJ Template was provided to the facility on [DATE] at 12:55PM. While the IJ was removed on 09/19/2024, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not Immediate Threat and a scope of Isolated due to the need for monitoring of corrective measures and the effectiveness of its corrective plan. This failure could place residents at risk for worsening of an ulcer, infection, and a…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-02 · 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 observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident#1) of 4 residents reviewed for ADLs. The facility failed to ensure Resident#1 had her fingernails cleaned and trimmed on 06/02/26. This failure could place residents at risk for loss of dignity, risk for infections, and a decreased quality of life. A record review of Resident #1's quarterly MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the diagnosis of: type 2 diabetes mellitus (elevated blood sugar), non-Alzheimer's dementia (brain disorders causing cognitive decline due to factors other than Alzheimer's), and stroke. Resident #1's BIMS score was 3/15 indicating severe cognitive impairment. The review further reflected the resident received partial/maximal assistance with ADL'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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-19 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    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 acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 1 of 5 residents (Resident #73) reviewed for nutritional status. The facility failed to recognize, evaluate, and address timely interventions for Resident #73 when the Dietitian made the recommendation for it on 01/02/26. Resident #73 experienced weight loss of 7.07% (7.4 pounds) from 12/24/25 to 03/01/26. This failure could place residents at risk for improper care, weight loss, malnutrition, and overall health decline. Findings included: Review of Resident #73's admission MDS Assessment, dated 12/29/25, reflected she was an [AGE] year-old female who admitted to the facility on [DATE]. She had a BIMS score of 03 indicating she had severe cognitive impairment. Her active…

    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 before2026-03-19 · 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 assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 5 residents (Residents #2 and #31) reviewed for pharmacy services.1. LVN J failed to administer a Potassium Chloride Extended-Release tablet in the proper form, when she crushed the tablet, before administering it to Resident #2 through the resident's enteral feeding tube. 2. RN H failed to ensure Resident #31 received his morning dose of sodium chloride 1 gram when RN H prepared the medication and left it on the 100-hall medication cart. RN H did not return to administer the medication to Resident #31 when he came back to the room.These failures could place residents at risk for ineffective drug therapy and medication error.Findings included:1. Record review of Resident #2's admission MDS dated [DATE] reflected the resident was a [AGE]…

    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 before2025-11-19 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    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 food that accommodates resident allergies, intolerances, and preference for 1 (Resident #2) of 1 resident reviewed for food preferences. The facility failed to ensure Resident #2 was given a substitute food item. This failure could place residents at risk of not eating their meals, further resulting in weight loss, and poor quality of life.Findings included:Record review of Resident #2's face sheet, dated 09/23/2025, revealed a [AGE] year old female, admitted on [DATE] with primary diagnosis of chronic diastolic (congestive) heart failure and other diagnoses included history of transient ischemic attack (episode of stroke like symptoms) and cerebral infarction (stroke), spondylosis (degenerative change in the spine), gastro-esophageal reflux disease (chronic condition where stomach acid flows back into the esophagus), hypertension (high blood pressure), mild neurocognitive disorder (cognitive decline), hyperlipidemia (high levels…

    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 before2025-07-29 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to ensure residents received food that accommodate the allergies, intolerances, and preferences of 2 (Resident #1 and Resident #2) of 5 residents reviewed for food and nutrition services. 1. On 07/25/25 during dinner, the facility failed to accommodate the preference of Resident #1 when she was served a pork hotdog that caused her to become nauseous and vomit. 2. On 07/29/25 during lunch, the facility failed to accommodate the preference of Resident #2 when he was served beef tacos. The failure could affect residents who consumed food from the facility's kitchen by placing them at risk for allergic reactions, dissatisfaction, poor intake, weight loss, and decline in health. Findings include: Record review of Resident #1's face sheet, dated 07/29/25, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnoses included Syncope and Collapse (loss of consciousness and posture), Type 2 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 1 of 3 residents (Resident #47) reviewed for oxygen. The facility failed to have accurate physician orders for oxygen use for Resident #47. This failure could place residents who received oxygen therapy at risk for inadequate or inappropriate amounts of oxygen delivery and possible infection. Findings included: Record review of Resident #47's admission Record dated 01/08/25 reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE]. Record review of Resident #47's quarterly MDS, dated [DATE], reflected a BIMS score of 15, indicating cognition was intact. The resident's diagnosis included: stroke (poor blood flow to a part of the brain causing cell death), cancer (group of diseases involving abnormal cell growth that can spread to other parts of the body),…

    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 · E2025-01-13 · tag F0698 — failed to provide proper dialysis care — pattern
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #48) reviewed for dialysis. The facility failed to ensure dialysis communication forms were completed for Resident #48 before going for dialysis and after returning from dialysis treatment. This failure could place residents at risk of inadequate communication between the facility and dialysis center. Findings included: Record review of Resident #48's admission MDS assessment, dated 11/25/24, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #48 had a diagnosis of chronic kidney disease (a chronic condition that occurs when the kidneys can no longer filter waste from the blood and requires long-term dialysis or a kidney transplant to maintain life). She had a BIMS…

    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 · Ecited before2025-01-13 · 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 monitor and verify that the feeding tube is in the right location (e.g., stomach or small intestine, depending on the tube) before administering medications to prevent complications for 1 of 1 resident (Resident #92) reviewed for feeding tubes and for 1 of 2 refrigerators and 2 of 2 medication rooms reviewed for pharmacy procedures. 1. The facility failed to ensure LVN J checked for residual (the amount of liquid remaining in the stomach after an enteral feeding) before administering medication to Resident #92. This failure could place residents at risk for adverse effects due to inappropriate management of g-tube care. 2. The facility failed to ensure expired medications, 2 bottles of aspirin 325 mg with expiration dates of April 2024 and December 2024, 3 acetaminophen suppositories 650 mg with expiration dates of November 2024 and 2 acetaminophen suppositories with expiration dates of July 2024 were removed and destroyed. This failure…

    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 · E2025-01-13 · tag F0757 — failed to avoid unnecessary drugs — pattern
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident's drug regimen was free of unnecessary medication for 1 of 5 residents (Resident #89) reviewed for adequate monitoring of unnecessary medication. The facility did not monitor Resident #89 for side-effects related to the use of the anti-anxiety medication Buspirone, hypnotic medication Zolpidem Tartrate, and the anti-psychotic medication Ingrezza. This failure could place the residents at risk for adverse consequences of medication. Findings included: Record review of Resident #89's admission record, dated 01/08/25, reflected the resident was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #89's quarterly MDS Assessment, dated 12/09/24, reflected she had a BIMS score of 11, indicating mild cognitive impairment. Further review revealed she had active diagnoses of progressive neurological conditions (conditions characterized by 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 · Ecited before2025-01-13 · 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 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 of 10 residents (Residents #7 and #9) reviewed for infection control. 1. The facility failed to ensure CNA M used Personal Protection Equipment during urinary catheter care performed for Resident #7 while on EBP precautions. 2. The facility failed to ensure RN C used Personal Protection Equipment during medication pass and providing care for Resident #9's tube feeding cite while on EBP precautions. These failures could place residents at risk for cross contamination and the spread of infection. Findings included: Record review of Resident #7's face sheet dated 01/08/25 reflected Resident #7 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #7's quarterly MDS…

    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
Show the remaining 13 citations
  • Potential for harm · Dcited before2025-01-13 · 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 observation, interview and record review, the facility failed to provide the necessary services to maintain good grooming for a resident who is unable to carry out activities of daily living for 1 of 3 residents (Resident #14) reviewed for ADL care. The facility failed to ensure Resident #14 received grooming assistance to remove unwanted facial hair. This failure could affect the residents who require assistance with care from facility staff by placing them at risk for social isolation, loss of dignity and self-worth. Findings included: Record review of Resident #14's MDS assessment, dated 11/02/24, reflected the resident was a [AGE] year-old female initially admitted to the facility on [DATE] and most recently admitted on [DATE]. Resident #14 admitted to the facility with diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels), heart failure, diabetes mellitus (a group of diseases that result in too much sugar in the blood), aphasia (a language disorder that affects…

    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 · D2025-01-13 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    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 interview and record review, the facility failed to ensure a resident with an indwelling urinary catheter received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #9) reviewed for catheter care. The facility failed to follow physician orders for routine catheter care including cleaning for Resident #9. This failure could place residents with foley catheters at risk of urinary infection and improper catheter care. Findings included: Record review of Resident #9's face sheet dated 01/13/25 reflected Resident #9 was a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #9's quarterly MDS dated [DATE] reflected Resident #9 was cognitively intact with a BIMS score of 13. The MDS indicated Resident #9 required substantial/maximum assistance with toileting, showering/bathing and personal hygiene. The MDS further reflected Resident #9 had an indwelling catheter. Resident #9'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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-13 · tag F0694 — isolated
    Provide for the safe, appropriate administration of IV fluids for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards for 1 of 2 residents (Resident #64) reviewed for intravenous fluids. The facility failed to ensure the dressing on Resident #64's peripheral intravenous line (a short flexible tube inserted into a vein to administer fluids and medications) was dated and initialed. The failures could affect residents by placing them at risk for infections. Findings included: Record review of Resident #64's entry MDS assessment, dated 12/27/24, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. The resident had diagnoses which included: urinary tract infection (a bacterial infection that causes inflammation in the urinary tract). Resident #64 had moderate cognition with a BIMS score of 11. She had intravenous access. Record review of Resident #64's physician's orders dated 01/06/25 reflected: May insert peripheral intravenous line 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-11-05 · 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 record reviews and interviews, 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 2 residents, reviewed for pharmaceutical services, in that: Medications must be released to residents only on the written or verbal authorization of the attending physician. When a resident is transferred directly to another nursing facility or discharged to home, the resident's medications must be released to the new facility or to the resident or his family, respectively. The facility failed to provide the correct medications to Resident #1 upon discharge and failed to provide the correct medication to Resident #2 upon discharge. The facility nurse failed to check for correct medication before releasing to the resident and/or family member. This failure could place residents at risk for the consequences of drug…

    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 before2023-12-20 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    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 observation, interview, and record review, the facility failed to ensure residents who are unable to carry out the activities of daily living received the necessary services to maintain personal hygiene for 3 of 6 residents (Resident #205, Resident #206, and Resident #209) reviewed for ADL care. The facility failed to ensure Resident #205 and #206 were provided regular showers. The facility failed to ensure Resident #209 was provided regular showers and personal hygiene based on the resident's preference. These failures could place residents at risk of not receiving personal care services and a decreased quality of life. Findings included: Resident #205 Record review of Resident #205's admission record, dated 12/20/2023, revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, and depression. Record review of Resident #205's admission MDS assessment, dated 12/10/2023 revealed a BIMS score of 13, indicating intact cognition. Record review of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-12-20 · 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 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 8 residents (Resident #355), reviewed for quality of care. 1. Facility failed to ensure an active order was followed for blood sugar monitoring for Resident # 355 from 12/12/23 to 12/19/23 as ordered by provider. 2. Facility failed to notify physician of an implanted continuous blood sugar monitoring medical device for Resident# 355. These failures could place residents at risk for inadequate care, inaccurate blood sugar results, infection at device site, and or bleeding. Findings included: Review of resident # 355 admission Recorded dated 12/19/23, reflected he was an [AGE] year-old man admitted to facility 12/07/23 with diagnoses of Congestive heart failure, chronic obstructive pulmonary disease with (acute) exacerbation, type 2 diabetes mellitus with diabetic chronic…

    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 · Ecited before2023-12-20 · tag F0692 — failed to prevent malnutrition and dehydration — pattern
    Provide enough food/fluids to maintain a resident's health.
    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 able to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that it was not possible, or the resident preferences indicated otherwise for 2 of 10 residents (Resident #205 and Resident #301) reviewed for quality of care. 1. The facility failed to weigh Resident #205 and #301 at admission per facility policy and physician's orders. 2. The facility failed to ensure Resident #301 did not have an unplanned significant weight loss. 3. The facility failed to ensure the Dietitian assessed Resident #205 upon admission. These failures could place residents at risk for decrease nutritional and weight status and a decline in health. Findings included: 1. Record review of Resident #205's admission record, dated 12/20/2023, revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses…

    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 · E2023-12-20 · 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, distribute and served food in accordance with professional standards for food safety in the facility's only kitchen reviewed for food and nutrition services. The facility failed to dispose of food items 72 hours after opening date in the walk-in refrigerator of the facility's kitchen. These failures affected residents by placing them at risk for contamination and food-borne illness. Findings included: An observation of the walk-in refrigerator on 12/18/23 at 8:35 AM revealed: - A pan dated 12/2 with 3 cucumbers open to air and one onion in a zip lock bag. One of the cucumbers was busted open and rotting with juice oozing out of it. - A container with left over cranberry sauce was dated 12/2. - A Ziploc back with tomato sauce was dated 12/6. In an interview on 12/18/23 at 8:38 AM the Dietary Manager stated they had just opened a new can of cranberry sauce three days prior, but they did not change the date on the container they were storing it in. He stated items were to be thrown out 72 hours after…

    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 before2023-12-20 · 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 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 disease and infections for 4 (Residents #10, #47, #94, #355) of 8 residents reviewed for infection control. 1. Facility failed to ensure the Dietary Manager wore proper Personal Protective Equipment (PPE) (gown, face shield, gloves, and N-95/KN95 respirator mask) before entering Resident #94 and Resident # 355's room that was on Transmission Based Precaution (isolation due to communicable infectious disease). 2. Facility failed to ensure LVN A, and CNA I wore proper Personal Protective Equipment (PPE) face shield while providing care in Resident's #10, #47, #48, #61 Transmission based precaution isolation (isolation due to communicable infectious disease) rooms. 3. Facility failed to ensure that MA G, and LVN J wore N-95/KN95 respirator mask with top…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-20 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to preserve the resident right to make choices about aspects of his or her life in the facility that were significant to the resident for 1 of 6 (Resident #305) reviewed for Resident Rights. The facility failed to respect the rights of Resident #305 regarding choice of food and care. This failure placed residents at risk of their rights being disregarded and a diminished quality of life. Findings included: Record review of Resident #301's Face sheet dated 12/04/23 revealed a [AGE] year-old female that admitted to the facility on [DATE]. She had a diagnosis list that included degenerative disc disease, degenerative joint disease of lumbar spine, osteopenia, retinal artery occlusion and scoliosis. Record review of Resident #301's MDS assessment dated [DATE] revealed a BIMS score of 12 which indicated moderate cognitive decline. Record review of Resident #301's Care plan last revised 12/11//23 did not address that resident was not eating due to not being…

    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 · D2023-12-20 · 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 develoop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #355) of 8 residents reviewed for comprehensive care plans. Facility failed to complete a care plan for an implanted continuous blood sugar monitoring medical device for Resident# 355. This failure could place residents at risk for inadequate care, inaccurate blood sugar results, infection at device site, and or bleeding. Findings included: Review of resident # 355 admission Recorded dated 12/19/23, reflected he was an [AGE] year-old male admitted to facility 12/07/23 with diagnoses of Congestive heart failure, chronic obstructive pulmonary disease with (acute) exacerbation, type 2 diabetes mellitus with diabetic chronic kidney disease, type 2 diabetes mellitus with hyperglycemia, type…

    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 · D2023-12-20 · 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, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for one of ten residents (Resident #55) reviewed for pharmacy services. The facility failed to ensure Resident #55 did not have unsecured medication in her room on 12/18/23 and 12/19/23. This deficient practice could place residents at risk of not being monitored for their medications, adverse reactions, and drug diversion. Findings included: Record review of Resident #55's admission Record dated 12/20/23 reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #55 was not her own responsible party. Resident had diagnoses which included cerebral infarction (stroke), major depressive disorder, bipolar disorder, cognitive communication deficit and need for assistance with personal care. Record review of…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-09 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    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 make prompt efforts to resolve grievances for 1 of 5 residents (Resident #1) reviewed for grievances. The facility failed to document, investigate, and respond to Resident#1's family member/visitor's complaint communicated to the Administrator regarding missing clothing items. This deficient practice could contribute to the resident's frustration and feelings of hopelessness. The findings were: The review of Resident #1's face sheet dated 8/9/23 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis included osteoarthritis (Degeneration of joint cartilage), Atrial Fibrillation (Irregular Heart rate), and hypertension (High blood pressure). An interview with Residents #1's family member on 08/07/23 at 1:23PM revealed when Resident #1 was admitted to the facility all her clothes were dirty, so they were taken in a clear plastic bag down to the laundry service, but nothing was ever returned. He stated another family…

    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

“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

$19,083 in federal fines across 1 penalty.

  • $19,083 — penalty dated 2024-09-19

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 HMG HEALTHCARE — 31 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 3 of 53.1-0.1 vs chain
Health inspection 3 of 52.8+0.2 vs chain
Staffing 3 of 51.8+1.2 vs chain
Quality measures 4 of 54.4-0.4 vs chain
The other 30 homes this chain runs (chain average 3.1★, per CMS)
1 of 5Deerbrook Skilled Nursing and Rehab CenterHumble, TX 1 of 5Park Manor of Cypress StationHouston, TX 1 of 5Silver SpringAbilene, TX 1 of 5Smoky Hill Rehabilitation CenterSalina, KS 1 of 5Tanglewood Nursing & RehabilitationTopeka, KS 1 of 5Treviso Transitional CareLongview, TX 2 of 5Accel at College StationCollege Station, TX 2 of 5Park Manor Of TomballTomball, TX 2 of 5Park Manor of Quail ValleyMissouri City, TX 2 of 5Park Manor of WestchaseHouston, TX 3 of 5Arbrook PlazaArlington, TX 3 of 5Cimarron Place Health & RehabilitationCorpus Christi, TX 3 of 5Green Oaks Nursing & RehabilitationArlington, TX 3 of 5Hewitt Nursing And RehabilitationHewitt, TX 3 of 5Methodist Transitional Care Center-Desoto LLCDesoto, TX 3 of 5Red Oak Health and Rehabilitation CenterRed Oak, TX 3 of 5Willowbrook Nursing CenterNacogdoches, TX 4 of 5Friendship Haven Healthcare And Rehabilitation CenFriendswood, TX 4 of 5Gulf Pointe PlazaRockport, TX 4 of 5Mission Nursing and Rehabilitation CenterMission, TX 4 of 5Park Manor Of HumbleHumble, TX 4 of 5Park Manor Of South BeltHouston, TX 4 of 5Park Manor Of The WoodlandsThe Woodlands, TX 5 of 5Crowley Nursing And RehabilitationCrowley, TX 5 of 5Harbor Lakes Nursing And Rehabilitation CenterGranbury, TX 5 of 5Holland Lake Rehabilitation And Wellness CenterWeatherford, TX 5 of 5Park Manor Of CyfairHouston, TX 5 of 5Pecan Bayou Nursing And RehabilitationBrownwood, TX 5 of 5Stallings Court Nursing and RehabilitationNacogdoches, TX 5 of 5Stonegate Nursing And RehabilitationFort Worth, TX

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
MURRELL, EDWARDIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 04/01/2018
ROLLO, JEFFERYIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 04/01/2021
STRAMECKI, ANTHONYIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 04/01/2021
VRATIS, KACEYIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 04/01/2021
WAY, GEORGEIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 04/01/2021
HEB SNF OE, LPOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 09/01/2023
HMG HEALTHCARE LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 09/01/2023
HMG PARTNERS I, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 09/01/2023
HMG SNF I, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 09/01/2023
BALSAMO, KRYSTALIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2021
CULP, ROLANDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2021
DASPIT, LAURENCEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2021
DOHN, WILLIAMIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2021
GADBERRY, DYLANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/05/2023
JAMES, JAMESIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/04/2022
PICO, ANAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2021
PRINCE, DEREKIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2021
REINARZ, CHRISTIANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2021
STANBRIDGE, NORMAIndividualADP OF THE SNFsince 04/01/2021

CMS files one row per role, so the 33 rows in the source record cover these 19 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.

4 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.

$10.0M
Net patient revenuemost recent cost report
-2.8%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 53%Medicare 9%Other / private 38%

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$302per resident / day
operating cost
$9,175per month
≈ monthly operating cost
$294per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in TX

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 676405. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-19, 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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