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Cibolo Creek

1440 River Rd, Boerne, TX 78006 · Government - Hospital district · 120 certified beds · (830) 816-5095 Medicare & Medicaid certified

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Abuse/neglect citation on record (F0602) — cited Dec 20232 immediate-jeopardy citations2 immediate-jeopardy citations CMS recorded as corrected before the inspection ended (past non-compliance)$13,627 in federal fines1 Medicare payment denial
Insights

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

Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0602), cited Dec 2023
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • inspectors recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $13,627 in federal fines (most recent 2024-11-23)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • nursing-staff turnover (61%) runs well above the national median (45%)

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

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

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1018 River Rd · (830) 356-2900 · Call to confirm hours
Pharmacy
910 River Rd · (830) 816-5312 · Call to confirm hours
Grocery
Bigs 305<0.1 mi
369 S Esser Rd · (830) 331-4002 · Call to confirm hours
Park
106 City Park Rd · (830) 249-9511 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 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 held steady at 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
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 increased9.4%15.8%15.4%better
Long-stay residents who lose too much weight2.2%3.0%5.4%better
Long-stay residents with a catheter left in their bladder0.9%0.3%0.9%typical
Long-stay residents with a urinary tract infection0.8%0.8%2.0%typical for the state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms1.3%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 injury2.3%3.3%3.3%better
Long-stay residents whose ability to walk worsened8.7%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication16.0%18.0%18.9%better
Long-stay residents given the seasonal flu vaccine98.6%98.0%95.3%typical
Long-stay residents with pressure ulcers7.8%3.8%4.7%worse
Long-stay residents with worsening bladder/bowel control16.8%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table9.3%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication1.8%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine87.9%88.0%79.4%better
Short-stay residents rehospitalized after admission26.6%25.7%22.6%worse
Short-stay residents with an outpatient ER visit14.2%12.3%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.022.171.67better
Long-stay outpatient ER visits per 1,000 resident days1.082.061.80better

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

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

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

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

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

53.6% 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 118 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

53.6%U.S. median 51.5%
Got home and stayed home
9.9%U.S. median 10.7%
Went back to hospital
60.3%U.S. median 56.6%
Met the expected recovery
0.41U.S. median 0.31
Therapy hours / resident / day
0.26hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 60.3% 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 78 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 0.41 therapist hours per resident per day in 2026Q1 — more than 70% 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 SNF53.6%CMS range 44.6–60.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.9%CMS range 7.2–13.410.7%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 discharge60.3%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 discharge47.4%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 discharge52.6%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 identified99.2%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 discharge97.7%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 stay0.8%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 worsened5.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.4%CMS range 3.6–11.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.061.02Oct 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

0.46
RN hours/ resident / day
0.99
LPN hours/ resident / day
1.54
Aide hours/ resident / day
3.00
Total nurse hours/ resident / day
0.20
RN hoursweekends
60.8%
Total nursing turnover
58.3%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 88.5 residents a day — about 74% occupied, or roughly 32 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.00 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.54 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.59 hrs/resident/day on weekends vs 3.16 on weekdays — 18% thinner on weekends. RN hours go from 0.56 to 0.20 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 61% is well above the national median of 45%. 3 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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 (2025-09-05)
5
at the previous standard inspection (2024-08-02)

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.

26 citations, most serious first. The 14 most serious are shown; the remaining 12 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2025-09-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible; and to ensure resident receives adequate supervision to prevent accidents for 1 of 2 residents (Resident #70) reviewed for accidents and hazards. The facility failed to ensure Resident #70 received adequate supervision when Resident #70 was missing on 8/28/2025 for approximately 45 minutes and found lying next to her wheelchair outdoors on an enclosed, outdoor patio. An IJ was identified on 9/3/2025. The IJ template was provided to the facility on 9/3/2025 at 12:10 PM. While the IJ was removed on 9/5/2025 at 10:09, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility needed to evaluate the effectiveness of the new procedures and training. This failure could place residents at risk of inadequate supervision 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · J2024-11-23 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to immediately consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status in life-threatening conditions for 1 of 5 residents (Resident #1) reviewed for change of condition, in that; The facility failed to notify Resident #1's physician and family on 11/18/2024 when she was found sleepier than usual or notify Resident #1's physician and the resident's family when the resident was found unresponsive and twitching with a significant alteration in mental status at approximately 5:00 a.m. on 11/19/2024 and was treated for altered mental status at the hospital. The noncompliance was identified as PNC. The IJ began on 11/18/2024 and ended on 11/19/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for serious harm, permanent disability and/or…

    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 · Past Non-Compliance
  • Immediate jeopardy · J2024-11-23 · 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 interviews and record reviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 5 residents (Resident #1) reviewed for quality of care, in that; The facility failed to immediately assess and intervene when Resident #1 was found unresponsive and twitching on 11/19/2024 at 5:00 a.m. by LVN A until the next shift arrived and LVN B intervened. This change of condition required treatment in a local hospital for altered mental status. The noncompliance was identified as PNC. The IJ began on 11/19/2024 and ended on 11/19/2024. The facility had corrected the noncompliance before the survey began. This deficient practice could affect residents who experience a change of condition and result in a delay in care, significant injury including permanent disability and death. The findings included: Record review of Resident #1's face sheet dated 11/20/2024…

    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 · Past Non-Compliance
  • Immediate jeopardy · Jcited before2024-11-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for 1 of 5 residents (Resident #1) reviewed for supervision, in that; The facility failed to adequately supervise Resident #1, who had a history of bringing multiple medications including narcotics into the facility without notifying staff, when she consumed a marijuana laced brownie and was found to have both Ambien and trazadone in an unmarked unlabeled container at bedside on 11/19/2024. On 11/19/2024, Resident #1 was found unresponsive and twitching in her room after staff failed to check on her between 11:00 p.m. on 11/18/2024 to 5:00 a.m. on 11/19/2024 despite seeing an unknown visitor in Resident #1's room on the evening of 11/18/2024 . This failure resulted in the identification of an Immediate Jeopardy (IJ) on 11/22/2024 at 12:50 p.m. The IJ template was provided to the facility on [DATE] at 1:03 p.m. While the IJ was removed on 11/23/24 the facility remained out 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 · Ecited before2025-09-05 · tag F0607 — failed to have anti-abuse policies — pattern
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, and record reviews the facility failed to implement written policies and procedures that Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, by not screening staff annually for 3 of 7 staff (MA AG, FSM, AD) employed longer than 1 year in that: Medication Aide (MA AG did not have a current EMR/NAR. FSM did not have a current EMR/NAR. AD did not have a current EMR/NAR. The failure could place residents at risk of being abused, neglected, or exploited by unemployable staff. The finding were: Record review of the policy on Abuse/Neglect and Misappropriation, dated 2025 was documented, the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Screening, a. Potential employees will be screened for a history of abuse, neglect, exploitation, o misappropriation of resident property. 1. Background,. Checks shall…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-09-05 · 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 for 1 of 1 kitchen in accordance with professional standards for food service safety. 1. The facility failed to maintain the temperature of walk-in refrigerator at or below 41 degrees F for the last 3 months2. The facility failed to take temperatures for the cold foods (to include milk for 09/05/25 breakfast and fresh fruit cups for 09/05/25 lunch). 3. The facility failed to ensure food products were labeled with discard dates. These failures could place residents at risk for food borne illness.The findings included:Record review of facility's Resource: Refrigerator/Freezer Temperature Log for the walk-in refrigerator, dated June 2025, reflected the following days had temperatures that were above 41 degrees Fahrenheit:(day: degrees Fahrenheit for morning and/or evening)2: morning 423: evening 434: morning 43 and evening 435: morning 437: morning 428: morning 429: evening 4211: morning 4312: morning 4214: morning 43 and evening 4315: evening 4316: morning 4317:…

    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 before2025-09-05 · 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 interviews, and record reviews the facility failed to ensure the medical records. In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are Complete; Accurately documented; Readily accessible; and systematically organized for 3 _of 16 (#20, #38, #5) residents reviewed for clinical records in that:1.Resident #20 did not have a current care plan conference meeting documented in her file. 2. Resident #38 did not have a current care plan conference meeting documented in her file. 3. The facility failed to ensure accurate documentation of Resident #5's July MAR per doctor's orders. These failures could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records.The findings included: Record review of Resident #5's admission record, dated 09/05/2025, reflected resident was a [AGE] year-old male initially admitted [DATE] and re admitted [DATE], with diagnoses to include…

    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 · E2025-09-05 · tag F0908 — failed to keep essential equipment working — pattern
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 walk-in refrigerators reviewed for essential equipment. The facility failed to ensure the walk-in refrigerator in the kitchen was functioning properly. This failure could place residents at risk for foodborne illness.The findings included:Record review of facility's Resource: Refrigerator/Freezer Temperature Log for the walk-in refrigerator, dated June 2025, reflected the following days had temperatures that were above 41 degrees Fahrenheit:(day: degrees Fahrenheit for morning and/or evening)2: morning 423: evening 434: morning 43 and evening 435: morning 437: morning 428: morning 429: evening 4211: morning 4312: morning 4214: morning 43 and evening 4315: evening 4316: morning 4317: morning 4318: morning 4219: morning 4222: morning 4224: morning 4325: morning 4226: morning 43 and evening 4228: morning 4329: morning 43 Record review of facility's Resource: Refrigerator/Freezer Temperature Log for the walk-in 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-05 · 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 interview, observation, and record review, the facility failed to ensure a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 8 residents (Resident #9) reviewed for care plans. The facility failed to revise Resident #9's comprehensive care plan to reflect the resident's ADL self-care performance for transfers. These deficient practices could place residents at risk of receiving improper care.The findings were: Record review of Resident #9's admission record, dated 09/04/2025, reflected resident was a [AGE] year-old male initially admitted [DATE] and re admitted [DATE], with diagnoses to include dementia (loss of cognitive functioning that interferes with daily life and activities), muscle weakness, acquired absence of left leg above knee (04/01/2023), and acquired absence of right leg below knee (12/31/2018). Record review of Resident #9's quarterly MDS assessment, dated…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-11-23 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 6 residents (Residents #2 and #3) reviewed for medications and pharmacy services, in that: The facility failed to ensure Resident #2 clobetasol propionate 0.05% prescription shampoo and over-the-counter polysporin were secured when they were left in the resident's room. The facility failed to ensure Resident #3's Simbrinza ophthalmic suspension x 2 bottles and 5 medication cups of an unknown ointment were secured when the resident was not in the room. These deficient practices could put residents at risk for inaccurate or inappropriate administration of medications. The findings were: 1. Record review of Resident #2's face sheet dated 11/23/2024 revealed an admission date of 11/09/2024 with diagnoses which included: atrial fibrillation…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-23 · 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 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, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for care plans, in that; The facility failed to develop a person-centered care plan with interventions that addressed Resident #1's behaviors of bringing in medications from home, from other providers and from visitors and self-medicating without telling staff. This failure could place residents at risk for not having their needs and preferences met. The findings were: Record review of Resident #1's face sheet dated 11/20/2024 revealed an admission date of 10/15/2024 with diagnosis which included: displaced bimalleolar fracture of left lower leg (broken bone of the ankle), subsequent encounter for closed fracture with…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-23 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, that are complete; and accurately documented for 1 of 5 residents (Resident #1) reviewed for medical records, in that; The facility failed to ensure staff documented Resident #1's unresponsiveness and SBAR assessment, the pills found in her room on 11/19/2024 or interventions for her change of condition including notification/activation of 911 and transfer to the hospital for treatment. This failure could result in residents not having an accurate overall view of their care and services. The findings were: Record review of Resident #1's face sheet dated 11/20/2024 revealed an admission date of 10/15/2024 with diagnosis which included: displaced bimalleolar fracture of left lower leg (broken bone of the ankle), subsequent encounter for closed fracture with routine healing, complete rotator cuff tear or rupture of right shoulder (muscles and tendons which…

    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 · E2024-08-02 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 3 of 8 residents (Residents #19, #21 and #49) who were observed for call light placement. The facility failed to ensure the call light was within reach for Residents #19, #21, and #49. This deficient practice could affect any resident and keep them from calling for help as needed. The findings included: Record review of Resident #19's face sheet, dated 08/01/2024, reflected she was admitted to the facility on [DATE] with diagnoses which included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, and anxiety, age-related osteoporosis without current pathological fracture, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting, unspecified side, weakness, and other abnormalities of gait and mobility. Record review of Resident #19's Quarterly MDS assessment, dated…

    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 before2024-08-02 · 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 and prepare food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: 1. [NAME] I was not wearing a moustache or beard guard while preparing food. 2. The walk-in refrigerator and walk in freezer both contained improperly stored food items. These deficient practices could place residents who consumed meals and/or snacks from the kitchen at risk for food borne illness. The findings were: 1. Observation on 07/30/2024 at 9:36 a.m. revealed [NAME] I was standing at the kitchen range and preparing the lunchtime meal. Further observation revealed three containers of food were on the kitchen range and were uncovered. Additional observation revealed [NAME] I had a moustache and a beard and was not wearing a moustache restraint or a beard restraint. During an interview, at the same time as the observation, [NAME] I stated that he does not wear moustache or beard restraints, had never been directed to do so, and said, I don't know if we have any [restraints].…

    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
Show the remaining 12 citations
  • Potential for harm · E2024-08-02 · 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

    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 infection for 3 of 9 residents (Residents #4, #30 and, #24) reviewed for infection control, in that: 1. Medication Aide F did not sanitize the blood pressure cuff between Residents #4 and #30. 2. While providing catheter care for Resident #24, CNA G and CNA H did not change their gloves or wash their hands after touching the privacy curtain and the environment outside of the room. These deficient practices could place residents at-risk for infection due to improper care practices. The findings include: 1. Record review of Resident #4's face sheet, dated 08/01/2024, revealed an admission date of 03/25/2022 with diagnoses which included: Dementia (General decline in cognitive ability), Major depressive disorder (Mood disorder characterized by pervasive low mood, low self-esteem, and loss of interest in doing…

    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 · D2024-08-02 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 residents have a right to personal privacy for 1 of 6 residents (Resident #18) reviewed for privacy, in that: ADON A did not close completely Resident #18's privacy curtain while providing wound care. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy. The findings include: 1. Record review of Resident #18's face sheet, dated 08/01/2024, reflected an admission date of 06/18/2024 and, a readmission date of 07/18/2024, with diagnoses which included: Osteomyelitis (infection of bone) left ankle and foot, Moderate intellectual disability, Osteoporosis (Systemic loss of bone mass resulting in fragile bones), Pressure ulcer of heel, stage 4 (wound exposing the bone). Record review of Resident #18's Significant change of status MDS assessment, dated 07/25/2024, reflected the resident had a BIMS score of 05, indicating she was severely cognitively impaired. Resident #18 was always incontinent of bladder and bowel and, required extensive assistance to total care with…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-02 · 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 reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 18 residents (Resident #52) whose assessments were reviewed, in that: Resident #52's Significant change MDS, dated [DATE], incorrectly documented the resident as receiving an injection of insulin. This failure could place residents at-risk for inadequate care and services due to an inaccurate assessments. The findings were: 1. Record review of Resident #52's face sheet, dated 07/31/2024, revealed an admission date of 06/17/2021 and, a readmission date of 06/20/2024 with diagnoses that included: Dementia (General decline in cognitive ability), Hemiplegia (Weakness of one entire side of the body), Alpers disease (Genetic disorder causing brain and liver damages), Type 2 diabetes mellitus (High blood sugar levels). Record review of Resident #52's Physician orders and Medication administration record for June 2024 revealed orders for: Trulicity Subcutaneous Solution Pen-injector…

    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 · D2023-12-29 · 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 residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 3 residents (Resident #1) reviewed for misappropriation. The facility failed to prevent misappropriation of property when CNA B took money via cash app and directly from a bank card from Resident #1 in the amount of $920.99 dollars. The non compliance was identified as past noncompliance. The noncompliance began on 09/29/23 and ended on 09/29/23. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of misappropriation which could lead to further exploitation of other residents. Findings included: Record review of Resident #1's electronic face sheet, dated 12/29/2023, indicated Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included mechanical complication of nephrostomy catheter (small tube draining urine from…

    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 before2023-12-29 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of property . The facility failed to follow its hiring policy and hired a nurse aide who had an extensive criminal history of theft and had a bar to employment of robbery on her record which resulted in the misappropriation of property of Resident #1. The non compliance was identified as past noncompliance. The noncompliance began on 09/29/23 and ended on 09/29/23. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of abuse, neglect, and exploitation due to staff not properly screened for employability. The findings included: Record review of Resident #1's electronic face sheet, dated 12/29/2023, indicated Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included mechanical complication of nephrostomy…

    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 before2023-12-29 · 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, interviews and record reviews, 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 of two residents (Residents #2 and #3) out of 13 residents reviewed for medication administration., in that: The facility failed to ensure Resident #2 was discharged from the facility with only his prescribed medication. The facility failed to ensure Resident #3 was given his prescribed medication prior to his discharge. The non compliance was identified as past noncompliance. The noncompliance began on 10/05/23 and ended on 10/07/23. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk for not receiving the appropriate care and services to maintain their health and safety. The findings included: Record review of Resident #2's admission Record dated 12/28/23 documented an 84-…

    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 · Past Non-Compliance
  • Potential for harm · F2023-05-26 · tag F0847 — widespread
    Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview the facility failed to ensure the Arbitration Agreement contained all the required elements for 1 of 1 facility. The facility failed to ensure the arbitration agreement contained the required elements: 1. The non-compulsory condition of admission in signing the arbitration agreement. 2. The acknowledgment of understanding the arbitration agreement. 3. The right to rescind the agreement within 30 calendar days of signing. 4. The retained ability to contact advocates and government representatives. This failure could place the residents and their representatives at risk of being uninformed about their rights regarding binding arbitration and less able to defend their rights related to disputes, controversy or claims arising out of or related to the services provided by the nursing facility. The findings included: During the entrance conference on 5/23/2023 at 9:03 AM with the ADM, a blank copy of the facility's admission packet and the binding Arbitration Agreement were requested, and these were received by the survey team on 5/23/2023 by 5:00 PM.…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-05-26 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that residents were free of any significant medication errors for 3 (Resident #234, #233, and #75) of 6 residents reviewed for safe administration of midodrine [a medication intended to raise systolic blood pressure], in that: 1. Resident #234 was administered midodrine on 4 instances outside of the parameters established by the Primary Care Physician (PCP) to hold if greater than 160 systolic blood pressure between 5/01/2023-5/25/2023; 2.Resident #233 was administered midodrine on 3 instances outside of the parameters established by the Primary Care Physician (PCP) to hold if greater than 160 systolic blood pressure between 5/01/2023-5/25/2023; 3.Resident #75 was administered midodrine on 4 instances outside of the parameters established by the Primary Care Physician (PCP) to hold if greater than 160 systolic blood pressure between 4/01/2023-5/25/2023; This failure could place residents at risk of not receiving the intended…

    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 · D2023-05-26 · 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 ensure residents who were unable to carry out activities of daily living [ADLs] were provided with the necessary services to maintain good personal hygiene for one resident of six reviewed (Resident #44) for ADL care, in that The facility failed to ensure Resident #44 was provided bathing as scheduled: Resident #44 was not provided 6 of 11 scheduled showers. This deficient practice could place residents who require assistance from staff for personal hygiene at risk of not receiving care and services to meet their needs and not reaching their highest practicable physical and psychosocial well-being. The findings were: Record review of the admission record dated 5/26/2023, revealed Resident #44 was a [AGE] year-old female with an initial admission date of 7/19/2019. Record review of the comprehensive MDS assessment dated [DATE], revealed Resident #44 was admitted under the primary medical condition category of other neurological conditions…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-26 · tag F0808 — failed to follow doctor-ordered diets — isolated
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to assure that residents receive a therapeutic diet as prescribed by the physician for 1 of 1 resident (#52) reviewed for diets in that: Resident #52 was prescribed a renal diet (A renal diet is one that was low in sodium, phosphorous, and protein. A renal diet also emphasizes the importance of consuming high-quality protein and usually limiting fluids. Some patients may also need to limit potassium and calcium) and was provided a regular diet which did not meet his special dietary needs. This failure could affect residents who are prescribed renal diets and could result in potassium building up in the blood stream and could result in a heart attack. The findings were: Review of Resident #52's electronic face sheet dated 05/26/2023 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: WEDGE COMPRESSION FRACTURE OF THIRD LUMBAR VERTEBRA, SUBSEQUENT ENCOUNTER FOR FRACTURE WITH ROUTINE HEALING (spinal…

    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 before2023-05-26 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: 1. The facility failed to maintain the cleanliness of the ice maker found within the kitchen. 2. The facility failed to prevent residents from receiving food that had made contact with an un-sanitized work surface. These failures could place residents at risk for cross-contamination and foodborne illnesses. The findings included: Observation on 5/24/23 at 10:51 AM revealed black substance build-up within the ice maker in the kitchen. Interview on 5/24/2022 at 11:11 AM, the DM stated the kitchen staff was responsible for emptying and cleaning out the ice maker every 3 months by draining and emptying the ice maker and cleaning it from the inside. He stated once every 6 months the MS will come and do a deep clean of the ice maker if it was required to do a deeper clean. The DM stated he did not notice the black substance build-up and could not…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-26 · tag F0848 — isolated
    Provide a neutral and fair arbitration process and agree to arbitrator and venue.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview the facility failed to ensure the Arbitration Agreement contained all the required elements for 1 of 1 facility. The facility failed to ensure the arbitration agreement contained the selection of a neutral venue that is convenient for both parties. This failure could place the residents and their representatives at risk of being uninformed about their rights regarding binding arbitration and less able to defend their rights related to disputes, controversy or claims arising out of or related to the services provided by the nursing facility. The findings included: During the entrance conference on 5/23/2023 at 9:03 AM with the ADM, a blank copy of the facility's admission packet and the binding Arbitration Agreement were requested, and these were received by the survey team on 5/23/2023 by 5:00 PM. The ADM stated during the entrance conference that the facility did not utilize arbitration agreements in admission. Record review of the facility's admission agreement, undated, reflected an Arbitration Agreement located on page 11 through 13 of 15 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.

    Administration 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

$13,627 in federal fines across 1 penalty. 1 Medicare payment denial on record.

  • $13,627 — penalty dated 2024-11-23
  • Medicare payment denial — starting 2025-10-04 for 11 days

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

Who owns this facility

Owner / managerTypeRoleShareSince
MEDINA COUNTY HOSPITAL DISTRICTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 05/01/2021
BELL, BILLIEIndividualCORPORATE OFFICERsince 06/03/2023
CASCADE-KENDALL HEALTH SERVICES, LTDOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 05/01/2021
HANEY, RONALDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2021
DORROW, MARJORIEIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 11/17/2025
HANEY, MAXIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 11/17/2025
BOERNE HC LLCOrganizationADP OF THE SNFsince 05/01/2021
COLLIER, TAYLORIndividualADP OF THE SNFsince 08/22/2023
SORRELLS, JOHNIndividualADP OF THE SNFsince 05/01/2021

CMS files one row per role, so the 10 rows in the source record cover these 9 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.

$8.2M
Net patient revenuemost recent cost report
-3.1%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 53%Medicare 11%Other / private 35%

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

$268per resident / day
operating cost
$8,157per month
≈ monthly operating cost
$260per 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 676240. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-05, 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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