Settlers Ridge Care Center
1280 Settlers Ridge Rd, Celina, TX 75009 · Non profit - Corporation · 128 certified beds · (972) 382-8600 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- 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
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (2/5)
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) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 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 | 8.2% | 15.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.0% | 3.0% | 5.4% | check this* — see note marked star below the table |
| Long-stay residents with a catheter left in their bladder | 0.2% | 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 | 0.4% | 2.4% | 6.5% | better than state‡ — see note marked double-dagger 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 | 9.9% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 3.7% | 14.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 31.3% | 18.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.2% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 5.5% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 20.1% | 9.6% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 76.1% | 88.0% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 28.2% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 3.3% | 12.3% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.79 | 2.17 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.16 | 2.06 | 1.80 | better |
* 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.
43.1% 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 48 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 57.8% 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 45 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 0.29 therapist hours per resident per day in 2026Q1 — more than 44% 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
| 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 | 43.1%CMS range 35.4–54.9 | 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 | 9.5%CMS range 5.6–14.5 | 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 | 57.8% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 53.3% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 57.8% | 50.0% | Oct 2024–Sep 2025 | CMS 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 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 | 6.8%CMS range 4.0–12.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.94 | 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 128 beds and averages 106.2 residents a day — about 83% occupied, or roughly 22 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 3.20 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.19 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.21 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 2.88 hrs/resident/day on weekends vs 3.33 on weekdays — 14% thinner on weekends. RN hours go from 0.19 to 0.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 43% 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
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.
- Potential for harm · E2026-04-02 · 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, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 5 of 5 residents (Resident #33, #57, #10, #65, and #16) reviewed for comprehensive care plans.The facility failed to ensure Resident #33, #57, #10, #65 and #16's comprehensive care plan addressed their goals, needs, strengths, medical, nursing, mental, and psychosocial needs.This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans.Findings included:Record review of Resident #33's MDS assessment dated [DATE], reflected an [AGE] year-old female, admitted to the facility on [DATE], with a BIMS score of 4 which indicated severe cognitive impairment. Diagnoses included: Chronic Heart Failure…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-04-02 · 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 observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen safety. The facility failed to ensure food in the facility's dry storage, and refrigerator areas were labeled and dated according to guidelines. The facility failed to seal lids securely on containers in the refrigerator area and dry storage pantry. These deficient practices could affect residents who received meals or snacks from the kitchen and place them at risk for cross contamination and other food-borne illnesses.Findings Included: 3/31/2026 Dry Pantry area revealed 12 plastic round maroon bowls had plastic lids that were unsealed, exposed to the air, not labeled and not dated. 3/31/2026 Walk-in refrigerator revealed 1 clear plastic container with a red cracked lid unsealed and exposed to the air. 9:12am on 3/31/26-Brief tour of the kitchen and interview with Director of Nutritional Services revealed, the facility has 1 kitchen and 1 main dining room.…
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 · E2026-04-02 · 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 essential equipment in operating condition by failing to maintain walk-in refrigerator and walk-in freezer coolant fans for 1 of 1 kitchens reviewed for equipment in operating condition. The facility failed to maintain the coolant fans in the walk-in freezer and in the walk-in refrigerator for operating condition.The facility's failure to maintain coolant fans in operating condition had the potential to place all residents at risk for cross-contamination and increased risk of foodborne illness. Findings Included:Walk-in refrigerator revealed dripping liquid from the coolant fan within the refrigerator. Walk-in freezer revealed ice build up on the coolant fan within the freezer. Observations of the kitchen during the brief initial tour of the kitchen on 03/31/26 at 9:12am revealed the following: 9:12am-Brief tour of the kitchen and interview with Director of Nutritional Services revealed, the facility has 1 kitchen and 1 main dining room. Conducted a brief walk through the walk-in freezer, and walk-in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-02 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a therapeutic diet that take into account the resident's clinical condition for one (Resident #86) of six residents reviewed for diet status and maintenance. The facility failed to offer Resident #86 the right diet as indicated in the residents' physician orders. These failures could increase the resident's risk for aspiration and choking. Record Review of Resident #86's admission MDS dated [DATE] reflected Resident #86's admission date of 03/18/26. She was [AGE] year-old female with active diagnoses included: acute respiratory failure with hypoxia, pneumonia, and pleural effusion (buildup of excess fluid between the layers of the pleura outside your lungs), malnutrition (imbalance between the nutrients your body needs to function and the nutrients it gets) and dysphagia (difficult swallowing). Nutrition and swallowing status reflected the resident had loss of liquids/solids from mouth when drinking or eating, holding food in 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.
- Potential for harm · D2026-04-02 · 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 interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 5 Residents reviewed for medication administration (Resident #26). The facility failed to ensure Resident #26 swallowed his medication before the staff member left the resident's room. This failure could place Residents at risk for missed doses, ineffective treatment, and potential decline in condition.Findings Included:Record review of Resident #26's Quarterly MDS Assessment, dated 03/23/26, reflected the Resident was a [AGE] year-old male with a BIMs score of 11 indicating he was moderately cognitively impaired. His diagnoses included: Coronary Artery Disease (a condition where the arteries that supply blood to the heart become narrowed or blocked by plaque, a buildup of fatty deposits, cholesterol, and other substances), Hypertension (blood…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-02 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 store drugs and biologicals in locked compartments based on the needs of one of five residents (Resident #16) reviewed for medication storage.The facility failed to ensure Resident #16 did not have unsecured Glipizide 10 MG tablet (an oral medication used to treat Type 2 Diabetes) in his room.This failure could place residents at risk for compromised medication efficacy, unsafe administration, and increased harm to residents.Findings Included:Record review of Resident #16's MDS assessment dated [DATE], reflected a [AGE] year-old male, admitted to the facility on [DATE]. The Resident's BIMS score was 8 which indicated moderate cognitive impairment. The Resident had diagnoses that included: Alzheimer's Disease (a brain disease that slowly destroys memory, thinking, and the ability to carry out daily tasks), Type 2 Diabetes (a condition where the body can't properly use sugar for energy, leading to high blood sugar and possible…
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 · E2025-12-15 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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 observations, record review and interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for residents in 2 (Shower room [ROOM NUMBER] and Shower room [ROOM NUMBER]) of 5 shower rooms reviewed for environment. 1. The facility failed to properly clean and sanitize the floor, toilet and sink of Shower room [ROOM NUMBER] and failed to empty the trash and soiled linen bins. 2. The facility failed to properly clean and sanitize the floor of one of the showers in Shower room [ROOM NUMBER]. This failure could affect all residents that were showered in the shower rooms by exposing them to bacteria and organisms that could impact their health and diminish their quality of life. The findings include: Record review of a grievances filed on 10/27/25 revealed a resident relative requested a cleaner environment for their relative at the facility. During an observation of Shower room [ROOM NUMBER] on 12/15/25 at 9:55am revealed a strong odor of urine as upon entrance to 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.
- Potential for harm · D2025-06-18 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to immediately inform the resident, consult with the resident's physician, notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 4 resident (Resident #1) reviewed for notification of changes. The facility failed to notify Resident #1's physician when an injury of unknown origin was discovered on 5/06/2025. This deficient practice could place residents at risk of not having their physician informed when there was a change in condition resulting in a delay in medical intervention and decline in health. Findings include: Record review of Resident #1's Face Sheet revealed that the resident was a [AGE] year-old female. She was admitted to the facility on [DATE] and discharged on 5/06/2025. She was a respite care (temporary care services) resident. Diagnoses of Alzheimer's disease (brain condition that progressively damages…
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 · D2025-06-18 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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 all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities, in accordance with State law through established procedures for 1 of 4 residents (Resident #1) reviewed for reporting. The facility failed to report an injury of unknown origin that was discovered on 5/06/2025, to HHSC. This failure could place residents at risk for not having incidents reported…
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 · E2025-02-20 · 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
Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 10 residents (Resident #23, Resident #22, Resident #72, and Resident #64) observed for infection control. 1. The facility failed to ensure MA C administered Resident 23's medication without cross contaminating her medications on 02/18/25. 2. The facility failed to ensure MA B prepared Resident 72's medication without cross contaminating her medications on 02/18/25. 3. The facility failed to ensure MA B sanitized the blood pressure cuff between use on Resident #22 and Resident #72 on 02/18/25. 4. The facility failed to ensure that CNA D changed her gloves and performed hand hygiene while providing incontinence care to Resident #64 on 02/18/25. 4. The facility failed to ensure the Treatment Nurse used the required PPE for Resident #64, who was on enhanced barrier precautions due to her venous…
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 · D2025-02-20 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 resident (Resident #205) reviewed for intravenous fluids. RN A failed to change Resident #205's Central Venous Catheter line dressing using sterile technique. This failure could affect residents by placing them at risk for infections and cross-contamination. Findings include: Record review of Resident #205's Minimum Data Set Assessment, dated 02/11/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE], his BIMS score was 15/15 indicating intact cognition. His diagnoses included blood stream infection due to central venous catheter, respiratory failure, pneumonia (an infection that inflames the air sacs in one or both lungs). Record review of Resident #205's Order Summary Report, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-20 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 Residents (Resident #64) reviewed for respiratory care. 1. The facility failed to obtain an order for Resident #64's use of supplemental O2 with stated liter amount to be delivered. 2. The facility failed to include rationale for the use of O2 for Resident #64 from 02/16/25 through 02/18/25. These failures could place residents who received oxygen therapy at risk of receiving an incorrect amount of oxygen and the risk of oxygen toxicity. Findings Included: Record review of Resident #64's significant change MDS assessment dated [DATE], reflected an [AGE] year-old female with a re-entry date of 12/06/24 to the facility. She had a BIMS score of 9 which indicated her cognition was moderately impaired. Diagnoses 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 before2024-11-20 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident#1) of 6 residents reviewed for ADLs. The facility failed to ensure Resident #1 had his fingernails cleaned and trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life. Findings included: Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 was an [AGE] year-old male with initial admission date to the facility on [DATE]. His diagnoses included fracture of part of neck of left femur (the bone of the thigh), Obstructive uropathy (urine cannot drain through the urinary tract), and Alzheimer's disease. Resident #1 had a BIMS of 99 which indicated Resident #1 was unable to complete brief interview for mental status. Resident #1 required…
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 · D2024-11-20 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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 one (Resident #2) of one resident reviewed for catheter care. The facility failed to ensure LVN B maintained Resident #2's indwelling urinary catheter drainage bag below the bladder level during wound care on 11/19/24. This failure placed residents at risk for not receiving care appropriate to address their incontinence and risk for infection. Findings included: A record review of Resident #2's Quarterly MDS assessment dated [DATE] reflected Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included multiple sclerosis (a disease resulting in nerve damage), stage 4 pressure ulcer, and neuromuscular dysfunction of bladder (the nerves and muscles of the bladder don't communicate properly with the brain, resulting in bladder control issues). Resident #2 had a BIMS of 12…
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 before2024-01-25 · 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 label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 (600 hall nurses' medication cart and 400 hall nurses' medication cart) of 4 medication carts reviewed for pharmacy services in that: The facility failed to ensure: 1- The 600 Hall medication cart had 2 insulin pens for Resident #18 without an opened date. 2- The 400 Hall medication cart had 1 insulin pen for Resident #54 without an opened date. These failures could affect residents resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications. The findings include: 1- Record review of Resident #18's Quarterly MDS, dated [DATE], revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses included type 2 diabetes mellitus, elevated blood…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-01-25 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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 food with appetizing temperature for one (01/24/24 breakfast) of one meal reviewed for appetizing temperature. The facility failed to serve eggs and oatmeal that had a palatable texture during the breakfast meal on 01/24/24. This failure could affect residents by placing them at risk of weight loss, altered nutritional status, and a diminished quality of life. Findings included: Review of Resident #7's quarterly MDS assessment dated [DATE] reflected Resident #7 was an [AGE] year old female admitted to the facility on [DATE]. Resident #7 had a BIMS of 9 indicating she was moderately cognitively impaired. Interview on 01/23/24 at 9:25 AM with Resident #7 revealed breakfast was late today and her eggs were cold. She stated hall trays get served last if they chose to eat in their rooms. Review of Resident #10's quarterly MDS dated [DATE] reflected Resident #10 was a [AGE] year-old male admitted to the facility on [DATE]. Resident #10…
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 before2024-01-25 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for one (Resident #5) of eight residents reviewed for ADLs. The facility failed to ensure Resident #5 had her fingernails cleaned and trimmed. This failure could place residents at risk for loss of dignity, risk for infections, and a decreased quality of life. Findings include: Record review of Resident #5's quarterly MDS assessment, dated 01/11/24, reflected a [AGE] year-old female with an admission date of 08/14/14. Resident # 5 was unable to participate in the brief interview for mental status and staff had assessed her to be severely cognitively impaired. Resident #5 was dependent for all ADLs and had no history of refusing care. Active diagnoses included cerebral vascular accident (stroke), hemiplegia (paralysis), heart failure and dementia. Record review of Resident #5's comprehensive care…
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 · D2024-01-25 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
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 with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one (Resident #5) of three residents reviewed for range of motion. The facility failed to implement interventions to prevent further decline of Resident #5's contracture to her right and left hands after discharge from occupational therapy on 11/13/23. This failure could place residents at risk for decline in range of motion, decreased mobility, and worsening of contractures. Findings included: Record review of Resident #5's quarterly MDS assessment, dated 01/11/24, reflected a [AGE] year-old female with an admission date of 08/14/14. Resident # 5 was unable to participate in the brief interview for mental status and staff had assessed her to be severely cognitively impaired. The Resident had lower extremity impairment on both sides. Resident #5 was dependent for all…
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 · D2024-01-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents for two (Resident #17, Resident #72) of eight Residents reviewed for accidents/hazards/supervision/ devices. The facility failed to properly maintain wheelchairs for Residents #17 and Resident# 72. This failures could affect the resident by placing the residents at risk for discomfort, pain, and injuries. Resident #17 Record review of Resident #17's quarterly MDS assessment dated [DATE] revealed resident was a [AGE] year-old female with an admission date of 03/10/2023. Resident #17 had a BIMS score of 9 indicating moderate cognitive impairment. Resident #17 required 2-person assistance with transfers, and she used a manual wheelchair for mobility. Resident #17 had an active diagnosis of Non-Traumatic Brain Dysfunction (injury to the brain), End-Stage Renal Disease (kidney failure), Muscle weakness, type 2 diabetes mellitus with diabetic nephropathy…
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 · D2024-01-25 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide behavioral health services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of one (Resident #7) of four residents reviewed for behavioral health services. The Social Worker failed to follow up to ensure Resident #7 received a psychiatric service after a referral was made on 11/02/23. This failure could place residents at risk for not receiving behavioral health services and a decline in Quality of life. Findings Included: Record review of Resident #7 quarterly MDS assessment dated [DATE] reflected an [AGE] year-old female with an admission date of 10/31/23. Resident #7 had a BIMS of 9 which indicated she was moderately cognitively impaired. There were no behaviors, signs of delusions or rejection of care noted on the assessment. Resident #7 had active diagnosis which included Alzheimer's, dementia with unspecified severe psychotic disturbance (suggestive of mental or emotion unsoundness…
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 · D2024-01-25 · 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 observation, interview and record review, the facility failed to ensure residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a condition as diagnosed and documented in the clinical record, and the resident received behavioral interventions unless clinically contraindicated in an effort to discontinue these drugs for 1 (Resident #86) of 5 residents reviewed for unnecessary medications. The facility failed to attempt gradual dose reduction for Resident #86's Divalproex (antipsychotic) and Seroquel (antipsychotic) medications. The facility failed to have specific side effect monitoring for Resident #86s Divalproex and Seroquel medications. These failures could place residents at risk for possible adverse side effects, adverse consequences, and decreased quality of life. Findings included: Review of Resident #86's face sheet dated 01/25/24 reflected Resident #86 was a [AGE] year old female admitted to the facility on [DATE] with diagnoses 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 · Dcited before2024-01-25 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 for one of one kitchen reviewed for kitchen sanitation. The facility failed to ensure Dietary Aide O had an effective hair restraint during breakfast meal serving on 01/23/24. This failure could place residents at risk for food-borne illness and food contamination. Findings include: Observations on 01/24/24 from 8:37 AM to 9:01 AM during breakfast meal preparation revealed Dietary Aide O did not have a hair restraint covering the front of her hair about 1 inch on forehead and 1/2 inch in front of both ears while she plated food for resident hall trays. Interview on 01/24/24 at 9:08 AM with Dietary Aide O revealed she was unaware her hair restraint was not covering [NAME] her hair in the front. She stated she had been in-serviced on wearing effective hair restraint when in kitchen. Interview on 01/24/24 at 9:11 AM with the Dietary…
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
No federal fines in the current CMS record.
Part of a chain
This home belongs to STONEGATE SENIOR LIVING — 24 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 | 4 of 5 | 2.4 | +1.6 vs chain |
| Health inspection | 4 of 5 | 2.3 | +1.7 vs chain |
| Staffing | 2 of 5 | 2.3 | -0.3 vs chain |
| Quality measures | 4 of 5 | 3.8 | +0.2 vs chain |
The other 23 homes this chain runs (chain average 2.4★, 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 | Share | Since |
|---|---|---|---|---|
| SOUTH LIMESTONE HOSPITAL DISTRICT | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 02/27/2015 |
| UMB BANK NATIONAL ASSOCIATION | Organization | 5% OR GREATER MORTGAGE INTEREST | — | since 09/23/2021 |
| PRICE, LARRY | Individual | CORPORATE OFFICER | — | since 06/01/1982 |
| PF SETTLERS RIDGE SNF OPS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/23/2021 |
| STONEGATE SENIOR LIVING, LP | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/22/2022 |
| COATES, WILLIAM | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/14/2024 |
| CAMPBELL, SCOTT | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 12/02/2025 |
| CHANCE, JAMES | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 12/02/2025 |
| FISHER, JAMES | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 12/04/2025 |
| LANGDON, THOMAS | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 12/02/2025 |
| MCGEHEE, WILLIAM | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 12/02/2025 |
| TAYLOR, JOHN | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 12/02/2025 |
| LIFETIME WELLNESS, LTD. | Organization | ADP OF THE SNF | — | since 09/23/2021 |
| MARTUS FINANCIAL SERVICES, INC. | Organization | ADP OF THE SNF | — | since 12/31/2023 |
| PHARMERICA DRUG SYSTEMS LLC | Organization | ADP OF THE SNF | — | since 08/27/2017 |
| PRESERVATION FREEHOLD COMPANY | Organization | ADP OF THE SNF | — | since 09/23/2021 |
| REHAB PRO LP | Organization | ADP OF THE SNF | — | since 09/23/2021 |
| SANCTUARY LTC, LLC | Organization | ADP OF THE SNF | — | since 09/23/2021 |
| BHARDWAJ, AMIT | Individual | ADP OF THE SNF | — | since 05/18/2025 |
| REINS, EMILEE | Individual | ADP OF THE SNF | — | since 04/05/2023 |
CMS files one row per role, so the 23 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted.
10 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.
About 83% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1 paid to related parties (affiliated landlords or management companies) in its most recent 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 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
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
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 675969. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-02, 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.