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Kruse Village Senior Living Community

1700 E Stone St, Brenham, TX 77833 · For profit - Limited Liability company · 65 certified beds · (979) 830-1996 Medicare & Medicaid certified

Call the home — (979) 830-1996 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0744)
Insights

On the public record, this home looks stronger than most — but visit before you decide.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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

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

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
110 Highway 290 W · (979) 830-5584 · Call to confirm hours
Pharmacy
2105 S Day St · (979) 836-5264 · Call to confirm hours
Grocery
2508 S. DAY ST.
Park
1800 E Tom Green St · (979) 337-7250 · 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 4 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 fell from 4 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased9.8%15.8%15.4%better
Long-stay residents who lose too much weight5.5%3.0%5.4%typical
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection5.8%0.8%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.0%2.4%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury1.9%3.3%3.3%better
Long-stay residents on antianxiety or hypnotic medication8.3%18.0%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers7.1%3.8%4.7%worse
Long-stay residents with worsening bladder/bowel control9.3%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table5.2%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.4%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine100.0%88.0%79.4%better
Short-stay residents rehospitalized after admission32.6%25.7%22.6%worse
Short-stay residents with an outpatient ER visit23.5%12.3%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.122.171.67better
Long-stay outpatient ER visits per 1,000 resident days3.022.061.80worse

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

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

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

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

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

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

62.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 142 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

62.4%U.S. median 51.5%
Got home and stayed home
10.5%U.S. median 10.7%
Went back to hospital
66.7%U.S. median 56.6%
Met the expected recovery
0.33U.S. median 0.31
Therapy hours / resident / day
0.16hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 66.7% 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 75 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 0.33 therapist hours per resident per day in 2026Q1 — more than 54% of the 13,892 homes that report any therapy hours at all.

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

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF62.4%CMS range 54.1–69.751.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.5%CMS range 7.6–13.910.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge66.7%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 discharge61.3%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 discharge62.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care 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 discharge97.4%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.7%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.0%CMS range 4.0–11.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.981.02Oct 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

0.56
RN hours/ resident / day
0.75
LPN hours/ resident / day
2.52
Aide hours/ resident / day
3.83
Total nurse hours/ resident / day
0.36
RN hoursweekends
55.2%
Total nursing turnover
62.5%
RN turnover

How full it usually is: this home is certified for 65 beds and averages 51.9 residents a day — about 80% occupied, or roughly 13 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 3.83 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.52 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.48 hrs/resident/day on weekends vs 3.98 on weekdays — 13% thinner on weekends. RN hours go from 0.64 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 55% is about the same as the national median of 45%.

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

Inspection trend

5
deficiencies at the latest standard inspection (2026-05-07)
8
at the previous standard inspection (2025-03-11)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

21 citations, most serious first. The 10 most serious are shown; the remaining 11 are one tap away and print in full.

  • Potential for harm · Ecited before2026-05-07 · 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 observations, interviews, and record reviews, the facility failed to properly store, prepare, and distribute food under sanitary conditions in accordance with professional standards for food service safety for one of one kitchen.The facility failed to ensure Dietary Aide C used proper hand hygiene between tasks on 05/05/2026. This failure could place residents who ate food from the kitchen at risk for foodborne illness.Findings include:Observation on 05/05/2026 at 11:50 am, revealed Dietary [NAME] C was wearing gloves when she obtained a disinfectant rag out of the disinfectant water container. She touched the rag with all of her fingers on her right hand. Dietary [NAME] C cleaned the food prep area with the disinfectant rag. She placed the rag into the disinfectant container. Dietary [NAME] C reached for an ink pen and began to write information on small pieces of paper. She never changed her gloves during these tasks. Dietary [NAME] C began to place food in a silver container with aluminum foil on top of the containers from the food prep area to the rolling kitchen…

    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 · D2026-05-07 · 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 ensure the comprehensive care plan, consistent with resident rights, included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one of five residents (Resident #41) reviewed for care plans completion. The facility failed to ensure Resident #41's care plan was completed to reflect Resident #41 had a pacemaker.This failure could place residents at risk of not receiving appropriate interventions to meet their medical needs. Findings include:Record review of Resident # 41's face sheet, dated 05/05/2026, reflected a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with a diagnoses of presence of cardiac pacemaker ( a small, battery-powered medical device implanted under the skin, usually near the collarbone, to treat abnormal heart rhythms or heart failure), chronic atrial fibrillation, unspecified (an irregular and often very…

    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 · D2026-05-07 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that residents treatment and care in accordance with professional standards of practice for 1 of 5 residents (Resident #41) reviewed for quality of care. The facility failed to ensure that nursing staff ensured the pacemaker was being transmitted on Resident #41. This failure could place residents at risk for not being provided the care and treatment to meet their needs. Findings included: Record review of Resident # 41's face sheet, dated 05/05/2026, reflected a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with a diagnoses of presence of cardiac pacemaker (a small, battery-powered medical device implanted under the skin, usually near the collarbone, to treat abnormal heart rhythms or heart failure), chronic atrial fibrillation, unspecified (an irregular and often very rapid heart rhythm. It can lead to blood clots in the heart. The condition also increases the risk of stroke, heart failure and other…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-07 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for two of four residents reviewed for catheter care (Resident #5). The facility failed to ensure Resident #5's catheter was secured to his body with a catheter secure device per the care plan and physician's orders. This failure to secure catheters placed residents with urinary catheters at risk for traumatic removal and catheter acquired infections.Findings included:Record review of Resident #5's face sheet, dated 05/05/2026, reflected an [AGE] year-old-male admitted to the facility on [DATE] with diagnoses which included chronic kidney disease, stage 3 unspecified (the kidneys are moderately damaged, with a 40-70 percent reduction in function. The exact substage is not defined), neuromuscular dysfunction of bladder, unspecified (a condition where nerve damage disrupts communication between the brain 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
  • Potential for harm · D2026-05-07 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 3 medication carts (Medication Cart #1) reviewed for medication storage.The facility failed to ensure Medication Cart #1 was locked and medications were secured.This failure could place residents at risk of having unauthorized access to prescriptions, biologicals, and over-the counter medications.Findings included Observation on 05/07/2026 at 7:42 a.m. revealed the locking mechanism was protruding outward (indicated the medication cart was unlocked) on Medication cart #1 located on 400 hall near room # 404. There was not any staff in the hallway or at the nurses desk near the entrance to 400 hall. The door to room [ROOM NUMBER] was closed. Med- Aide B exited room [ROOM NUMBER] at 7:46 am.Interview on 05/07/2026 at 7:46 am Med-Aide B stated she forgot to lock the medication…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-03 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure residents were given the appropriate services to maintain activities of daily living (ADLs) for three of six (Resident #1, Resident #2, and Resident #3) residents. 1. Resident #1 had a soiled and stained top. 2. Resident #2 had soiled pants and unwanted facial hairs. 3. Resident # 3 had crumbs on the top of her blanket, unwanted facial hair, and had a brown substance under her fingernails. These deficient practices could place residents at risk of embarrassment and placing them at risk for social isolation, loss of dignity and self-worth. Findings included: 1. Record review of Resident #1's Face sheet dated 06/03/2025 revealed Resident #1 admitted on [DATE] was a [AGE] year-old female with diagnosis of Unspecified Dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), Epilepsy (is a brain disease that causes repeated seizures), Unspecified 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-03-11 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, observation, and record review, the facility failed, to provide an ongoing activities program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for residents residing on four of four halls. The facility failed to provide activities on the weekends for the months of February and March of 2025. This failure placed residents at risk for boredom, depression, increased behaviors, and diminished quality of life. Findings include: Review of activity participation binder on 03/10/2025 reflected group activities did not occur in the facility on the weekends for the month of February 2025 and two weekends in March 2025 (03/01/2025 to 03/02/2025 and 03/08/2025 to 03/09/2025). Review of the Activity Director Personnel Record on 03/11/2025 reflected the Activity's Director's date of hire was 11/04/2024 and she did…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-03-11 · 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 drug and biological) to meet the needs of each resident for 2 of 4 residents (Resident #14 and Resident #29) reviewed for medications and pharmacy services, in that: 1. The facility failed to ensure Resident #14's physician ordered medication Calcium and Gabapentin were available for administration. 2. The facility failed to ensure Resident #29's physician ordered medication Saccharomyces Baulardii (probiotic) was available for administration. These deficient practices could place residents at risk of not receiving therapeutic dosage of medications and symptomatic changes in vital signs. Findings include: 1.) Review of Resident #14's face sheet reflected an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses lumbar vertebra fracture (fracture of the spine), vitamin D…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-03-11 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 11.54% based on 3 out of 26 opportunities, which involved 2 of 4 residents (Resident #14 and Resident #29) and 1 of 1 MA's (MA E) observed during medication administration reviewed for medication error. 1. The facility failed to ensure Resident #14's physician ordered medication Calcium and Gabapentin was available for administration. 2. The facility failed to ensure Resident #29's physician orders medication Saccharomyces Baulardii (probiotic) was available for administration. These deficient practices could place residents at risk of not receiving therapeutic dosage of medications and symptomatic changes in vital signs. Findings include: 1.) Review of Resident #14's face sheet reflected an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses lumbar vertebra fracture (fracture of the spine),…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-03-11 · 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 observations, interviews, and record reviews the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety in one of one kitchen reviewed for kitchen and food sanitation. The facility failed to ensure [NAME] J wore gloves and used proper hand hygiene while preparing purée food for residents on 03/10/2025. The facility failed to ensure Culinary Aide I wore gloves while preparing a cake on 03/11/2025. These failures could have placed residents at risk for food contamination and foodborne illness. Findings included: Observation on 03/10/2025 at 11:11 AM revealed [NAME] J had just finished checking temperatures of the baked chicken, rice, and beans that she pulled out of the oven wearing an oven mitt, and then proceeded to purée beans in the grinder. [NAME] J did not wash her hands and did not put on gloves before starting the purée process. [NAME] J touched the inside of the grinder blade as she adjusted the grinder prior to putting the beans in the grinder. She stood with the palms of her hands touching the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · E2025-03-11 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of five residents (Resident #15) reviewed for infection control practices. The facility failed to ensure LVN D followed standard precautions during wound care on 03/10/2025 for Resident #15's Stage III pressure ulcer to her sacrum, when she failed to set up a clean wound dressing field without cross contamination and failed to use a cleaning technique on the pressure ulcer that did not cross contaminate the pressure ulcer or prevent the pressure ulcer once cleaned from becoming re-contaminated. This failure placed resident at risk for developing wound infections, and at risk for healthcare associated cross-contamination and infection. Findings included: Review of Resident #15's face sheet dated 03/10/2025…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-11 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    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 treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (Resident #160) of 6 residents reviewed for resident rights. The facility failed to cover Resident #160's catheter bag during therapy in the rehabilitation unit. This failure placed residents at risk of loss of dignity, embarrassment, and diminished quality of life. Findings include: Review of Resident #160's face sheet, dated, 03/05/2025, reflected an [AGE] year-old female who was admitted on [DATE]. Resident #160 had diagnoses which included retention of urine, unspecified (the condition where the bladder does not empty or cannot completely empty, leaving some urine behind), and neuromuscular dysfunction of bladder, unspecified (a medical condition where the bladder's muscles or the nerves controlling them are not functioning as they should, causing…

    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 · D2025-03-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that residents received care, consistent with professional standards of care to prevent development or worsening of pressure ulcers for one of three residents (Resident #15) reviewed for pressure ulcers. The facility failed to ensure LVN D followed standard precautions during wound care on 03/10/2025 for Resident #15's Stage III pressure ulcer to her sacrum, when she failed to set up a clean wound dressing field without cross contamination and failed to use a cleaning technique on the pressure ulcer that did not cross contaminate the pressure ulcer or prevent the pressure ulcer once cleaned from becoming re-contaminated. This failure could place residents at risk for worsening pressure ulcers leading to discomfort, pain, and potential infections. Findings included: Review of Resident #15's face sheet dated 03/10/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: dementia (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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-11 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure residents who are incontinent of bladder receive appropriate treatment and services to prevent urinary tract infections for two ( Resident #7 and Resident #160) of seven residents reviewed for catheters. The facility failed to prevent Resident #7's and Resident #160's catheter bag/tubing from touching the floor on 03/09/2025. These failures could place residents at risk for cross contamination and urinary tract infections. Findings included: Resident #7 Review of Resident #7's face sheet, dated, 03/09/2025, reflected a [AGE] year-old male who was admitted on [DATE] and readmitted on [DATE]. Resident #7 had diagnoses which included end stage congestive heart failure and renal (kidney) insufficiency. Review of Resident #7's MDS dated [DATE] reflected a BIMS score of 8, which suggested a moderate cognitive impairment. He had an indwelling catheter. Review of Resident #7's Baseline Care Plan, dated 02/20/2025, reflected Resident #7…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-26 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    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 a safe, clean, and homelike environment for 5 of 6 Resident' beds (Residents # 1, #2, #3, #4, and #5) observed for bed linens and failed to have clean towels and top sheets available in one of one rehabilitation units. The facility failed to ensure Residents #1, #2, #3, #4, and #5's beds had a top sheet. The facility failed to ensure there were clean towels and top sheets available in the Rehabilitation unit. These failures could place residents at risk of living in an un-homelike environment. Findings included: Record review of the undated Face Sheet for Resident # 1 reflected she was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Type 2 Diabetes (long term condition in which the body has trouble controlling blood sugar and using it for energy) without complications. Record review of Resident #1's Quarterly MDS dated [DATE] reflected she had a BIMS score of 12 indicating…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-31 · tag F0757 — failed to avoid unnecessary drugs — pattern
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs 3 of 7 residents (Residents #39, #44, and #47) reviewed for unnecessary medications. The facility did not have appropriate indications for medications based on Resident #39's diagnoses. The facility did not have parameters to hold blood pressure medication for Resident #39. The facility did not hold blood pressure medications for Residents #44 and #47 when the residents' blood pressure or pulse was outside parameters set by their physician. These failures could place residents at risk of complications related to receiving unnecessary medications. Findings included: 1. Record review of a face sheet dated 01/31/24 indicated Resident #39 was an [AGE] year-old male admitted on [DATE]. His diagnoses included atrial fibrillation (a type of irregular heartbeat), benign prostatic hyperplasia (a noncancerous enlargement of the prostate gland), cerebral infarction (lack of adequate blood supply…

    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 · E2024-01-31 · tag F0801 — pattern
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to employ sufficient staff with appropriate competencies and skill sets to carry out the functions of the food and nutrition service for 1 of 1 facility kitchen reviewed for food and nutrition services. The facility failed to designate a person to serve as the dietary manager who met the required qualifications. The facility designated Dietary Supervisor did not have a dietary manager's certification or any other qualifying credentials. This failure could place residents at risk for the spread of foodborne illness and residents not having their nutritional needs met. The findings include: Record review of the personnel file for the Dietary Supervisor indicated no documentation that she had completed the certified Dietary Manager course. She had a date of hire of 12/02/16. During an interview on 01/30/24 at 8:00 a.m., the Dietary Supervisor said she had not completed or started the dietary manager classes. She said she was working as dietary supervisor until the facility could hire a certified dietary manager. During an…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-31 · tag F0802 — failed to prepare enough nourishing food — isolated
    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 1 of 10 dietary staff (Dietary Aide B) reviewed for food and nutrition services. The facility failed to ensure Dietary Aide B had a current Food Handler's Certificate while working in the facility's kitchen. This failure could place residents who consumed food prepared in the facility kitchen at risk of foodborne illness due to being served by improperly trained staff. Findings included: Record review of 10 dietary staff food handlers' certificates indicated Dietary Aide B's certificate expired on 09/05/23. During an interview on 01/31/24 at 11:47 a.m., Dietary Aide B said he did not know his food handler's certification had expired last year. He stated, I completed the food handler training and tested last night. During an interview on 01/31/24 at 12:00 p.m., the Administrator said the Dietary Manager was responsible for monitoring the dietary staff and the food handler certificates. She said the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-31 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    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 liquids consistent to meet the residents' needs, for one (Resident #43) of 16 residents reviewed for food and nutrition services. The facility did not serve Resident #43 nectar thickened coffee or juice during his breakfast meal on 01/29/24. This failure could place residents who have dysphagia at risk for aspiration. Findings included: Record review of Resident #43's admission record dated 01/29/24 indicated he was [AGE] years old and admitted on [DATE] with aphasia (language disorder) and dysphagia (difficulty swallowing). Record review Resident #43's of the MDS quarterly assessment dated [DATE], indicated Resident #43's BIMS score was 09 indicating moderate impairment with cognition. He was dependent on staff for eating. Resident #43 required mechanically altered diet - required change in texture of food or liquids (thickened liquids) while a resident of this facility and within the last 7 days. Record review of the care plan…

    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 · D2024-01-31 · 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, interview and record review, the facility failed to ensure residents were provided the therapeutic diets as prescribed by the attending physician for 2 of 16 residents (Residents #18 and #40) reviewed for therapeutic dietsfood and nutrition services. The facility failed to ensure Residents #18 and #40 did not received their health shake with the lunch meal on 01/29/24 as ordered by physician. This failure could place residents with diet needs at risk for a decrease in calories and potential weight loss. The findings included: 1. Record review of Resident #18's admission record dated 01/31/24 indicated she was [AGE] years old and admitted on [DATE] with vitamin deficiency and heart disease. Record review of the MDS quarterly assessment dated [DATE], indicated Resident #18's BIMS score was 08 indicating moderate impairment with cognition. She required supervision for eating. No weight loss or gain of 5% or more in the last month or loss of 10% or more in the last 6 months was noted. Record…

    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 · D2023-10-04 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident who displayed or was diagnosed with dementia received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being, for one1 of 5 residents (Resident #1) reviewed for treatment and services. The facility failed to develop and implement a comprehensive person-centered care plan to address Resident #1's continuous intermittent aggressive behaviors toward male residents. This failure placed residents at risk for their medical, physical, and psychological needs not being met. Findings included: Review of Resident #1's Face Sheet dated 10/04/2023 reflected a [AGE] year-old female admitted to the facility 09/01/2022 with the following diagnoses Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.) Major Depression (A mental condition characterized by a persistently depressed mood and long-term loss of pleasure 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to HEALTH DIMENSIONS GROUP — 10 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 53.2+0.8 vs chain
Health inspection 4 of 52.8+1.2 vs chain
Staffing 3 of 54.0-1.0 vs chain
Quality measures 4 of 53.7+0.3 vs chain
The other 9 homes this chain runs (chain average 3.2★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleSince
DIMENSIONS HEALTH STRATEGIES CORPORATIONOrganizationDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 12/02/2016
HENNESSEY, ERINIndividualINDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2020
ROGOTZKE, AMBERIndividualINDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2020
HEALTH DIMENSIONS CONSULTING INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/06/2025
BRISCOE, DAVIDIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2020
BRISCOE, PATRICIAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2020
SHVETZOFF, SERGEIIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2020
SHVETZOFF, TAMIIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2020
OBAKPOLOR, OSAHONIndividualADP OF THE SNFsince 08/01/2024

CMS files one row per role, so the 15 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

$10.9M
Net patient revenuemost recent cost report
-7.9%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 15%Medicare 18%Other / private 67%

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$617per resident / day
operating cost
$18,768per month
≈ monthly operating cost
$572per 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 675837. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-07, 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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