Brady West Rehab & Nursing
2201 Menard Hwy, Brady, TX 76825 · For profit - Corporation · 106 certified beds · (325) 597-2906 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has 1 actual-harm citation
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $10,527 in federal fines (most recent 2024-08-22)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
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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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 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 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 11.0% | 15.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.3% | 3.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.0% | 2.4% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 7.5% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 3.6% | 14.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 12.0% | 18.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.5% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 8.6% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 5.3% | 9.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 88.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 16.8% | 25.7% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 24.8% | 12.3% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.48 | 2.17 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 3.06 | 2.06 | 1.80 | 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.
38.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 27 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.18 therapist hours per resident per day in 2026Q1 — more than 19% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 38.6%CMS range 27.4–53.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.4%CMS range 8.8–17.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.27 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 106 beds and averages 37.5 residents a day — about 35% occupied, or roughly 68 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 3.33 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.49 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.77 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 2.92 hrs/resident/day on weekends vs 3.49 on weekdays — 16% thinner on weekends. RN hours go from 0.53 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 46% 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
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.
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.
23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.
- Actual harm · G2024-08-22 · tag F0790 — failed to provide dental care — isolatedProvide routine and 24-hour emergency dental care for 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 observations, interviews, and record review, the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for 2 of 2 residents (Residents #2 and #20) reviewed for dental services. 1. The facility failed to assist in providing routine dental services for Resident #2 and Resident #20. This failure could place residents at risk of oral complications, dental pain, and diminished quality of life. Findings included: Resident #20 Review of Resident #20's admission Record revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included congestive heart failure (condition in which the heart does not pump blood well enough to give the body a normal supply), anxiety disorder, dental carries (cavities), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and recurrent major depressive disorder. Review of Resident #20's Care Plan, revision date 5/23/24, revealed: Focus - Resident #20…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-09-04 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for and 1 of 2 medication carts (Hall A & B nurse medication cart) reviewed for medication storage. The facility failed to ensure the nurses cart #1 for the A& B Hall did not contain insulin, and nebulizer treatment vials that were opened and not labeled with the open date. This failure could place residents at risk of adverse medication reactions.Findings included: Observation on [DATE] at 11:30 AM revealed the nurse's medication cart #1 for the A&B Hall had the following opened medications with no open date labeled: 1. 2 insulin glargine pens2. 2 boxes Ipratropium Bromide and albuterol sulfate inhalation nebulizer solution Interview on [DATE] at 11:31 AM with RN C, she said once insulin and nebulizers were opened, they…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-09-04 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 under sanitary conditions for 1 of 1 main kitchen in that: [NAME] B took the dinner rolls with her hands to place them on the residents plates when plating the lunch meal. These failures could place residents who ate food from the kitchen at risk of foodborne illness. Findings includedDuring an observation and interview on 09/03/2025 at 11:20 AM revealed [NAME] B was seen plating the meals for lunch time. [NAME] B was touching the meal tickets, using a suction grabber device to grab the hot plates and then using the serving ladles to place the food on the plates. [NAME] B was then seen taking a dinner rolls with her bare hands and placing them on the meal plates. The Culinary Manger was present in the kitchen at the time of the food being served. The Surveyor asked the Culinary Manager if it was okay for [NAME] B to be taking the rolls with her bare hands and placing them on the plate. The Culinary Manager said no and went and provided [NAME] B with a pair of tongs…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-09-04 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection 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 3 residents (Resident #5, and Resident #1) and 4 of 4 (NA #A, MA #F, ADON, and Director of Rehab) staff members reviewed for infection control in that;The facility failed to ensure NA A changed her gloves after they became contaminated during incontinent care while assisting Resident #5.The facility failed to ensure LVN B performed hand hygiene between glove changes while providing wound care for Resident #1.The facility failed to ensure NA #A, ADON, and Director of Rehab were tested for Tuberculosis (TB), a potentially serious infectious bacterial disease that mainly affects the lungs, upon hire.The facility failed to ensure MA #F and Director of Rehab completed a Tuberculosis Health Risk Screen upon hire and yearly. These…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-08-22 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure stored foods were properly stored, labeled, and dated. 2. The facility failed to ensure food items remained covered prior to food service. 3. The facility failed to ensure the refrigerator's thermometers reflected similar temperatures. 4. The facility failed to ensure expired food items were discarded by the expiration date. 5. The facility failed to maintain cleanliness in the kitchen. The dry storage had food particles on the shelves and the ice machine had a brown substance on the ice making mechanism. These failures could place residents who received prepared meals from the kitchen at risk for food borne illness and cross-contamination. The findings included: During the initial tour of the kitchen on 8/20/24 from 11:20 am to 12:00 pm the following observations were made: - A coffee filter was noted sitting on 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.
- Potential for harm · E2024-08-22 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 4 residents reviewed for care plans (Residents #18, #28, #32). 1. Residents #18, #28, and #32 did not have care plans in place to address their need for Enhanced Barrier Precautions (EBP). 2. Resident #32 did not have a care plan in place to address her pressure ulcer. These failures could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included: Resident #18 Review of Resident #18's admission Record revealed she was a [AGE] year-old female originally admitted to the facility on [DATE], with a most recent admission date of 3/16/22. She had diagnoses which included myelodysplastic syndrome (condition, considered a type of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-08-22 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (Resident #4) of 2 residents reviewed for incontinent care and 3 (Resident #18, #28, and #32) of 4 residents reviewed for Enhanced Barrier Protections (EBP) for infection control practices. 1. CNA B washed her hands then closed the faucet with her bare hands before providing personal care for Resident #4. CNA B also did not sanitize her hands in between glove change during personal care provided to Resident #4. 2. The facility failed to ensure Residents #18, #28, and #32 were identified for and implemented Enhanced Barrier Precautions related to pressure ulcers. These failures could place resident's risk for cross contamination and the spread of infection. Finding included: Resident #4 Record review of Resident #4'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.
- Potential for harm · Dcited before2024-08-22 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
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 resident's had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 2 of 5 residents (Residents #14, Resident # 17) reviewed for resident rights. The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #14's or their Responsible Party for Mirtazapine, an antidepressant used to treat depression (a mood disorder that causes a persistent feeling of sadness or loss of interest) prior to administering the medication. The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #17 or their Responsible Party…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-22 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to electronically transmit within 14 days after the facility completed a resident's assessment, encoded MDS data including a subset of items upon a resident's quarterly MDS assessment for 1 (Residents #27) of 6 residents reviewed for electronic transmission of MDS data to the CMS system. The facility failed to transmit quarterly MDS data to the CMS system within 14 days of the completion of Resident #27's quarterly MDS Assessment. This failure could place residents at risk of not having specific information transmitted in a timely manner. Findings included: Review of Resident #27's admission MDS Assessment, dated 3/26/24 revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including stroke, high blood pressure, high cholesterol, and dementia. He scored a 4 of 15 on his mental status exam (indicating severe cognitive impairment) and showed signs of delirium including inattention. Review of Resident #27's e-chart 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.
- Potential for harm · Dcited before2024-08-22 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 (Residents #2) of 15 residents reviewed for pharmaceutical services. LVN A did not administer Resident #2's scheduled multivitamin with minerals as indicated by the physician orders. These failures could place residents at risk of not receiving the therapeutic benefit of medications and under dosed. The findings were: Record review of Resident #2's admission Record, dated 08/21/2024, indicated she was admitted to the facility on [DATE] with diagnoses of anxiety and vitamin deficiency. She was [AGE] years of age. Record review of Resident #2's order summary report dated 08/21/2024 indicated in part: Multiple Vitamins with Minerals. Give 1 tablet by mouth one time a day for dietary supplement. Order status = active. Order date 08/30/20. Start date 06/07/22. During…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-12 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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 have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing for 5 (Residents #1, #2, #3, #4, and #5) of 10 residents reviewed for staffing concerns. 1. The facility failed to ensure there were sufficient staff per the facility assessment. 2. The facility failed to ensure there were sufficient staff to ensure Residents #1-#5 received their showers. This failure could place residents at risk of not getting needed care and services, a decrease in quality of care and quality of life and/or injury. Findings included: Resident #1 Record review of Resident #1's face sheet, dated 4/12/24, reflected a [AGE] year-old male with an admission date of 12/8/23. Resident #1 had a diagnosis which included Dementia, Hyperlipidemia, and muscle wasting. Record review of Resident #1'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.
Show the remaining 12 citations
- Potential for harm · E2024-04-12 · tag F0908 — failed to keep essential equipment working — patternKeep all essential equipment working safely.
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 all mechanical, electrical, and patient care Equipment in safe operating condition for 2 (Hot water heater #1 and #2) of 3 reviewed for essential equipment. The facility failed to repair or replace the hot water heater that supplied hot water for Halls 1, 2 and 3, 4 for days. This failure could place residents at risk for poor hygiene and health. Findings include: Observation on 4/10/24 at 4:15 AM revealed hot water in all showers on halls 1 (hot water heater #1) and 4 (hot water heater #2) went from hot water to cold water in 10 min. At 4:25 AM water in shower on hallway 1 was cold to touch. At 4:27 AM water in shower on hallway 4 was cold to touch. Record review of Plumbing company A dated 3/7/24 indicated work to be done on both water heaters by replacing piping on both water heater #1 and #2. Record review of Plumbing company B dated 4/3/24 indicated and estimate to have both hot water heaters replaced. During an interview on 4/8/24 at 10:10am with the facility Administrator stated that she first…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-12 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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 observations, interview and record review, The facility failed to maintain complete and accurately documented medical records on 3 (Resident #3, #6, and #7) of 9 residents reviewed. The facility failed to have matching documentation of shower logs vs shower task in electronic system for Residents #3, #6, and #7. This failure could place residents at risk of not having proper hygiene. Findings Included: Resident #3 Record review of Resident #3's face sheet, dated 4/12/24, reflected an [AGE] year-old female with an admission date of 2/15/24. Resident #3 had a diagnosis which included Orthopedic aftercare, type 2 diabetes mellitus, and hypothyroidism. Record review of Resident #3's MDS dated [DATE] with a quarterly assessment dated [DATE] indicated BIMS of 7, indicating moderate cognitive impairment. Record review of Skin observation worksheet indicated Resident #3 received showers on 3/21/24 and 4/3/24. Documented by CNA C. Record review of electronic system bathing task indicated Resident #3 did not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-03-21 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide 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, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 2 of 5 residents (Resident #1 and Resident #2) reviewed for respiratory care. Resident #1 and Resident #2 did not have physician's orders for oxygen administration. This deficient practice could affect the residents who received respiratory treatments and could result in residents receiving incorrect or inadequate oxygen support and could result in a decline in health. Findings include: Resident #1 Record review of Resident #1's face sheet, dated 03/21/24, revealed an [AGE] year-old female who was admitted to the facility on [DATE] with the diagnosis of Chronic Obstructive Pulmonary Disease - COPD (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and systolic and diastolic heart failure (a group…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-14 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections for one of three residents (Resident #1) reviewed for infection control practices. CNA A failed to perform proper hand hygiene and glove changes while providing incontinence care to Resident #1. This failure could place residents at risk for the spread of infection. Findings include: Record review of Resident #1's face sheet, dated 03/14/24, reflected an 81- year- old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included constipation, dysuria (discomfort when urinating), hemiplegia (partial paralysis) and hemiparesis (partial weakness). Record review of Resident #1's Quarterly MDS assessment, dated 03/07/24, reflected Resident #1 required substantial/maximal assistance with most…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-29 · tag F0806 — failed to honor food preferences — patternEnsure 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 interviews, and record reviews, the facility failed to provide food that accommodates resident's preferences for eight (Resident #1, #2, #3, #4, #5, #6, #7, and #8) of eight residents reviewed for food preferences and the accommodation of resident's meal choices. The facility kitchen failed to offer alternative meals for residents. This failure placed residents at risk for dissatisfaction, poor intake, weight loss and decline in health. Findings include: Resident #1 Record review of Resident #1's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis include Parkinson's Disease (progressive disorder that effects the nervous system), Anemia (low red blood cells that carry oxygen), Heart Failure, and Muscle Weakness. Record review of Resident #1's admission MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Resident #2 Record review of Resident #2's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnosis include 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.
- Potential for harm · E2023-12-07 · tag F0557 — patternHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
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 ensure residents had the right to be treated with dignity and respect for 2 (Resident #6 and Resident #8) of 3 residents who were reviewed for rights. For Resident #6 and Resident #8, the facility failed to move the residents' personal possessions when the residents were moved to a different room when the ceiling leaked. This failure placed the residents' property at risk for being lost, stolen, or damaged and could cause them worry and distress. Findings include: Record review of Resident #6's Face Sheet, dated 12/06/2023, revealed a [AGE] year-old female who was admitted to the nursing facility on 12/24/2020. Resident #6's diagnoses included Unspecified Dementia (mild memory disturbance due to known physiological condition), Unspecified Severity, without Behavioral Disturbance, and Type II Diabetes (condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). Record review of Resident #6'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.
- Potential for harm · E2023-12-07 · tag F0559 — patternHonor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
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 2 of 3 (Resident #6 and Resident #8) residents reviewed for rights, received written notice prior to room change. The facility failed to ensure Resident #6, and Resident #8 received written notice, or the responsible person was contacted prior to room change. The facility failure could place the residents at risk of decreased quality of life due to a change in living environment. Findings include: Record review of Resident #6's Face Sheet, dated 12/06/2023, revealed a [AGE] year-old female who was admitted to the nursing facility on 12/24/2020. Resident #6's diagnoses included Unspecified Dementia (mild memory disturbance due to known physiological condition), Unspecified Severity, without Behavioral Disturbance, and Type II Diabetes (condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). Record review of Resident #6's Annual MDS, dated [DATE], revealed a BIMS score of 12, which indicated moderate…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-12-07 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 2 of 4 halls (hall 1 and hall 4) and the 1 of 1 dining room reviewed for environmental conditions. 1. The facility failed to repair room [ROOM NUMBER] on Hall 1 that had severe water damage to the ceiling. 2. The facility failed to repair room [ROOM NUMBER] on Hall 4 that had severe water damage where the ceiling had fallen and caved in. 3. The facility failed to maintain the ice machine in the dining room to prevent water damage to the floor and mineral deposits to form on the outside of the machine. These failures could place residents at risk of being in an unsafe environment, a decrease in quality of life and self-worth. Findings include: During an observation on 12/06/2023 beginning at 12:02 p.m., observed an industrial size ice machine in the dining room area standing on discolored tile, that was stained, and water damaged.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-07-13 · tag F0552 — patternEnsure that residents are fully informed and understand their health status, care and treatments.
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 resident's had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 6 of 32 residents (Resident #7, Resident #18, Resident #20, Resident #21, Resident #23, and Resident #28) reviewed for resident rights . The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #7 prior to administering Nortriptyline, an anti-depressant medication used to treat depression (disorder characterized by persistently depressed mood or loss of interest in activities causing significant impairment in daily life). The facility failed to obtain informed consent based on information of the benefits,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-07-13 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 of 15 residents (Residents #18 #19, #21 and #29) reviewed for care plans in that: Resident #18 did not have a care plan to address his diuretic use. Resident #19 did not have a care plan for needs related to Parkinson's Disease (progressive disease of nervous system causing tremors, muscle stiffness, and slow imprecise movements). Resident #21 did not have a care plan to address his antipsychotic use or his antianxiety use. Resident #29 did not have a care plan to address his dietary preference of being a Vegetarian or signs and symptoms of delirium. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-07-13 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that ensure the accurate administering of all drugs to meet the needs of the residents, for 1 of 1 medication rooms (indicate which med room) inspected for medication storage, for 1 of 1 treatment carts (which med cart) inspected for medication storage, and for 1 of 31 residents reviewed for pharmacy services (Residents # 29) during review of medication carts. The facility failed to ensure the Review of the medication room revealed: opened and undated vials of influenza vaccine. Review of the wound care/ treatment cart revealed: Review of the medication cart revealed: expired medications in cart This failure could place residents at risk of receiving medications that were expired and not produce the desired effect. Findings included: Record review of Resident #29's admission record dated 07/13/23 indicated he was admitted to the facility on [DATE] with diagnoses which included…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-13 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 each resident's drug regimen was free from psychotropic drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for two (Resident #18 and #21) of 5 residents reviewed for unnecessary medications. Resident #18 was prescribed the antipsychotic Haloperidol for anxiety or restlessness. Resident #18 was prescribed the antipsychotic Haloperidol and the anti-anxiety Lorazepam as needed for greater than 14 consecutive days without the review of the prescribing doctor. Resident #21 was prescribed an anti-anxiety/antipsychotic medication diazepam/ Haloperidol gel for treatment of agitation, and the antipsychotic quetiapine for dementia. Resident #21 was prescribed an as-needed antipsychotic for more than 14 consecutive days without the review of the prescribing doctor. This failure puts residents at risk of medication adverse effects because of being administered unnecessary…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$10,527 in federal fines across 1 penalty.
- $10,527 — penalty dated 2024-08-22
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 RUBY HEALTHCARE — 7 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 2.9 | +2.1 vs chain |
| Health inspection | 4 of 5 | 2.0 | +2.0 vs chain |
| Staffing | 3 of 5 | 2.7 | +0.3 vs chain |
| Quality measures | 5 of 5 | 4.9 | ≈ chain avg |
The other 6 homes this chain runs (chain average 2.9★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| BARHAM, MARITIA | Individual | W-2 MANAGING EMPLOYEE | since 06/01/2023 |
| HARDIN, LESLIE | Individual | CORPORATE OFFICER | since 06/01/2023 |
| BRADY SNF, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 06/01/2023 |
| SILBERSTEIN, ARI | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 06/01/2023 |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner 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.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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
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
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 676034. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-04, 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.