Columbus Oaks Healthcare Community
300 North St, Columbus, TX 78934 · For profit - Corporation · 137 certified beds · (979) 732-2347 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- it has 2 actual-harm citations
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,412 in federal fines (most recent 2025-07-09)
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (1/5)
- nursing-staff turnover (56%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 1 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 | 1 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 1 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 3 to 1 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 | 24.2% | 15.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.9% | 3.0% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.0% | 2.4% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 8.3% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 13.0% | 14.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 18.5% | 18.0% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 98.7% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.1% | 3.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 7.4% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 21.0% | 9.6% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 7.7% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 87.5% | 88.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 23.3% | 25.7% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 14.0% | 12.3% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 3.32 | 2.17 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.67 | 2.06 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
43.4% 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 33 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 39.1% 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 23 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 0.55 therapist hours per resident per day in 2026Q1 — more than 85% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 43.4%CMS range 32.5–57.2 | 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 | 10.9%CMS range 7.1–15.5 | 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 | 39.1% | 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 | 39.1% | 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 | 34.8% | 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 | 96.9% | 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 | 12.5% | 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 | 7.2%CMS range 3.7–15.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.19 | 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 137 beds and averages 69.0 residents a day — about 50% occupied, or roughly 68 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Weekend coverage: total nurse staffing is 2.74 hrs/resident/day on weekends vs 3.35 on weekdays — 18% thinner on weekends. RN hours go from 0.19 to 0.03 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 56% is well above the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
30 citations, most serious first. The 12 most serious are shown; the remaining 18 are one tap away and print in full.
- Actual harm · G2025-07-09 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 6 Residents (Resident #20) whose records were reviewed for pain management. LVN H/Treatment Nurse, failed to ensure Resident #20 received a PRN pain medication prior to wound care. LVN H/Treatment Nurse failed to stop wound treatment when Resident #20 was grimacing and quizzing in pain on 7/8/25. This failure could affect any resident with DTR's, surgical wounds and pressure ulcer experiencing pain and mental distress.[SP1] .Review of Resident #20's face sheet, dated 7/7/25, revealed she was admitted to the facility on [DATE] with diagnoses cellulitis of right toe,) inflammation in your airways chronic obstructive pulmonary Disease cause breathing ( lung conditions that cause breathing difficulties), unspecified,…
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.
- Actual harm · G2023-03-17 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and observations, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one of three residents (Resident #1) reviewed for quality of care. - The facility failed to promptly identify skin redness to the peri area and buttocks, which had tiny openings on Resident #1, and failed to ensure interventions were implemented to treat and prevent skin deterioration. This failure could place residents at risk for a delay of care or treatment, pain, and suffering. Findings include: Record review of Resident #1's face sheet revealed a 58 year - old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses were non- pressure chronic ulcer buttock with unspecified severity, Cellulitis of buttock, dementia, and diabetes mellitus Record review of Resident #1's quarterly MDS dated [DATE] indicated a BIMS score of 00 revealed severely impaired cognitively. It further revealed the resident was…
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 before2026-04-01 · 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 observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 3 (Resident #5) reviewed for pharmaceutical services.-The facility failed to ensure Resident #5's medications on 01/13/2026 were documented as given during the night shift. -Resident #5 did not receive pain medication on 03/05/2026 at 8:00p.m. per physician orders.This failure could cause residents to have unnecessary and avoidable pain. Record review of Resident #5's medical records revealed, she was a [AGE] year-old female originally admitted on [DATE] with diagnoses including hypertension (high blood pressure), type 2 diabetes mellitus (high blood sugar, dementia (declining brain function related to thinking and judgement that is severe enough to impact daily life), atherosclerotic heart disease of native coronary artery without angina pectoris (a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-01 · 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
Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement.-The facility failed to ensure residents' lunch was served at a safe temperature on 3/31/2026. These failures could place residents who ate food from the kitchen at risk of foodborne illness and disease. In confidential interviews with residents in the facility, residents stated food was always cold when it arrived and they would prefer food to be warmer. Observation and interview with the Dietary Manager on 3/31/2026 at 12:30pm revealed, she took the temperature of the mixed vegetables consisting of peas and carrots which was 114.6F. The Dietary Manager brought a second bowl of mixed vegetables which she measured at 105.8F. The Dietary Manager said the temperature was not in range to be served to residents, the most the food temperature should have gone down to 135F holding temperature from the steam table to when it got to residents. 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.
- Potential for harm · Dcited before2026-04-01 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to 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 1 of 3 residents (Resident #4) observed for infection control.-The facility failed to ensure CNA GG washed her hands or used hand sanitizer after doffing gloves during incontinent care observation on 3/31/26.These failures could place the residents at risk of cross-contamination and development of infection. Record review of Resident #4's face sheet dated 04/01/2026 reflected an [AGE] year-old female was admitted on [DATE] and diagnoses include Alzheimer's disease (is a progressive neuro degenerative disorder that causes disorientation and behavioral changes, and obstructs memory, thinking and judgment), shortness of breath, hypotension (low blood pressure) and muscle wasting and atrophyRecord Review of Resident's #4's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-07-09 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 residents (Resident #20 and Resident #74) observed for infection control. 1. The facility failed to ensure TX Nurse used the required PPE for Resident #20, who was on enhanced barrier precautions on 7/8/25. 2. The facility failed to ensure CNA RS used the required PPE for Resident #74, who was on enhanced barrier precautions. These failures could place the residents at risk of cross-contamination and development of infection.1.Record review of Resident #74's face sheet reflected an admission date of 01/17/25. Resident #74's diagnoses included essential (primary) hypertension (high blood pressure) , hypothyroidism,( low thyroid hormones to meet the needs of the body), dementia ( problem with memory, thinking 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.
- Potential for harm · D2025-07-09 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to encode a resident's assessment within 7 days and complete and electronically transmit a resident's completed discharge MDS within 14 days for 2 ((Residents #36 and #67) of 2 residents reviewed for MDS transmittal.-Resident #36 passed away 3/8/2025 and Resident #67 passed away 4/11/2025 and their discharge MDS' were not encoded within 7 days after death and were not transmitted within 14 days after death. This failure could cause a resident's significant change such as their MDS to not be accurately reflected in their medical records. Record review of Resident #36's face sheet last updated 07/092025 reflected a [AGE] year-old male originally admitted on [DATE] with medical diagnoses including gout ( a form of arthritis affecting the joints), hypertension (high blood pressure), dementia (decline in cognitive function with symptoms including forgetfulness and limited social skills), Alzheimer's disease (progressive disease that destroys memory , thinking…
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 before2025-07-09 · 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 ensure residents who were unable to carry out activities of daily living received necessary services to maintain grooming and personal hygiene for one (Resident #6) out of eight residents reviewed for ADLs. The facility failed to provide skin care to Resident #6 which resulted in patches and dry flaky skin from below the knee to her feet. These deficient practices could place residents at risk of skin breakdown and reduced feelings of self-worth.Record review of Resident #6's face sheet dated 07/08/25 revealed a [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #6 had diagnoses which included, hypertension (when the pressure in the blood vessels is too high), heart failure (heart is not pumping blood as effective as it should) and dementia (decline in mental ability, severe enough to interfere with daily life, affecting thinking, and reasoning)Record review of Resident #6's quarterly MDS,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-09 · 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 residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #11) reviewed for incontinent care. 1. The facility failed to ensure CNA G cleaned Resident #11 properly during incontinent care on 7/8/25. This failure could place residents at risk for pain, infection and hospitalization. Record review of Resident #11's face sheet dated 7/7/25 reflected date of admission was 4/8/22 and re admitted on [DATE]. Resident #11's diagnoses included history of transient ischemic attack (tia)mild stroke) cerebral infarction ( stroke), unspecified, unspecified atrial fibrillation ( heart beating too fast), essential (primary) hypertension( high blood pressure), hypothyroidism ( thyroid gland isn't producing enough thyroid hormones), unspecified, edema, unspecified, hemiplegia and hemiparesis( weakness to one…
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 before2025-07-09 · 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 observation, interview and record review, the facility failed to maintain medical records on each resident that are accurately documented in accordance with accepted professional standards and practices and must 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 (Resident #41) of 5 residents reviewed for accurate documentation and pharmaceutical services. -Resident #41 was documented as receiving his Invega suspension prefilled syringe for his bipolar disorder on 7/4/2025 when he did not receive the medication. The medication was not in the building. This failure could put residents at risk of not receiving the needed treatments they need to promote their mental and physical well-being. Record review of Resident #41's face sheet last captured 7/9/2025 reflected a [AGE] year-old male originally admitted on [DATE] with medical diagnoses including Major…
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 before2025-07-09 · tag F0759 — failed to keep medication error rate low — isolatedEnsure 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 its medication error rate was not 5 percent or greater for. There were 2 errors out of 29 opportunities, which resulted in a 6 percent error rate involving Resident #28 and Resident #39 observed for medication pass in that: -Medication Aide FF did not administer Resident #28 Tylenol ES as ordered by the Physician.-Medication Aide RR did not check Resident #39's blood pressure prior to administering blood pressure medication hydralazine 10 mg 2 tablets by mouth.These failures placed residents at risk for increase pain and decrease in quality of life. Resident #28Record review of Resident #28's face sheet dated 07/07/25 revealed an [AGE] year-old female admitted to the facility on [DATE]. Resident's diagnoses included type 2 diabetes mellitus (when the body has trouble controlling blood sugar and using for energy) with diabetic chronic kidney disease, peripheral vascular disease (circulatory condition in which narrow blood vessels…
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 before2025-07-09 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that its residents are free of any significant medication errors for 1(Resident #39) 7 residents reviewed for significant medication errors.-Medication Aide RR did not check Resident #39's blood pressure prior to administering blood pressure medication hydralazine 10 mg 2 tablets by mouth.This failure placed residents at risk for dangerous drop in blood pressure, organ damage, increase risk of falls, and hospitalization.Record review of Resident #39's face sheet dated 07/07/25 revealed an [AGE] year-old male admitted to the facility on [DATE] and again on 07/03/25. Resident's diagnoses included hypertension (high blood pressure) and urinary retention (difficulty urinating and completely emptying the bladder).Record review of Resident #39's quarterly MDS dated [DATE] revealed a BIMS score of 13 indicating that resident cognition was intact. Further review section O (Special Treatments, Procedures, and Programs) reflected that…
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 18 citations
- Potential for harm · Dcited before2025-07-09 · 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 observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements and kitchen sanitation.-The facility failed to ensure foods stored in the walk-in cooler were labeled and dated.-The facility failed to ensure the kitchen back door was closed.-The facility failed to ensure the dry storage room floor did not have black build up on the floor and the walk-in-freezer did not have an accumulation of ice on the floor. These failures could place residents at risk of foodborne illness and food contamination.During an observation on 07/07/2025 between 8:21 a.m. and 9:12 a.m., the surveyor and the DM observed the following food items were opened and not dated with an open date, use-by date, and delivery date in the walk-in cooler:Walk-in Cooler:1. Two boxes of spread, 55% vegetable oil, were open, but there was no delivery date, open date,…
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 · D2025-07-09 · tag F0813 — isolatedHave a policy regarding use and storage of foods brought to residents by family and other visitors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to store foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for 1 of 1 resident fridges in the facility.-There was unlabeled and undated food was stored in the residents' refrigerator.-The residents' refrigerator had items belonging to nursing staff.This failure has the potential to place all the residents at risk for consuming food that has not been handled in a safe and sanitary manner. Observation on 07/08/25 at 2: 40 p.m., revealed there were items in the resident refrigerator near the front lobby which contained staffs' personal food items including: 1 fast food plastic orange container with the straw (undated), half-empty bag of tortilla chips (undated), three used water bottles, three lunch bags, two steel water containers, one glass coffee container, and one transparent container containing rice. There was also one plastic container of food dated 3-31 belonging to a resident. Interview on 07/08/25 at 2:43 p.m. with LVN T, he said he had been at 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 · Ecited before2025-04-03 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1of 5 residents (CR#1). The facility failed to ensure that CR#1's Lorazepam was ordered, received, and dispensed when CR#1 was admitted to the facility. This failure could place the residents at risk of not receiving the intended therapeutic benefit of the medications, decreased quality of life and hospitalization. Findings included: Record review of CR#1's admission face sheet, revealed he was a [AGE] year-old who was admitted on [DATE] and discharged on 03/14/2025. His diagnoses included hyperlipidemia (high level of fat in the blood), aggressive behavior (type of behavior intending to cause physical or mental harm), hypothyroidism (thyroid not producing adequate thyroid hormone), anxiety (mental health condition characterized by excessive worry and fear), Parkinson…
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 before2024-05-31 · tag F0759 — failed to keep medication error rate low — patternEnsure 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 the medication error rate was not 5 percent (5%) or greater for 3 of 30 opportunities resulting in a 10 percent medication error rate for 2 (Residents #11 and #67) of 6 residents observed for medication pass. Facility failed to ensure Resident #11 Sertraline dosage (Medication that works by increasing levels of a mood-enhancing chemical called serotonin in your brain: many people recover from depression and has fewer unwanted side effects than older antidepressants) was administered as per physician order. Facility failed to ensured Resident # 11 received Potassium Chloride as ordered. MA A initialed on MAR that Potassium Chloride was administered. Potassium Chloride ( ( medication use to prevent and treats low levels of potassium in your body. Potassium plays an important role in maintaining the health of your kidneys, heart, muscles and nervous system) Facility failed to ensure Resident #67 received Divalproex Sodium (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.
- Potential for harm · Ecited before2024-05-31 · tag F0760 — failed to prevent significant medication errors — patternEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure 1 of 6 residents (Resident #11) reviewed for medication administration were free of significant medication errors. Facility failed to administered Potassium Chloride Microencapsulated Crystals ER for 7 Days to Resident #11 This failure could place residents at risk of harm, injury, illness or hospitalization. Findings included: Record review of the face sheet, dated 05/31/24, for Resident #11 revealed that the resident was admitted to the facility on [DATE]. The resident was a [AGE] year old female and had diagnoses of seasonal allergic rhinitis, edema,(swelling), hypokalemia (low potassium level in the blood), depression ( common mental health condition that can affect how people feel, think, and behave, characterized by a persistent feeling of sadness and loss of interest in activities), essential (primary) hypertension( increased blood pressure), anxiety disorder( natural human response to stress or fear experienced through thoughts,…
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 before2024-05-31 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. 1. The facility failed to ensure expired foods were discarded. 2. The facility failed to ensure foods were labeled and dated. 3. The Facility failed to ensure food is properly stored in designated areas at all times. These failures could place residents who ate food from the kitchen at risk of food borne illness and disease. Findings Included: Observation of the facility kitchen on 05/29/24 at 8:15 AM revealed the following. 1. A Plastic Container of Sliced American Cheese was dated 5/21/24 use by date 5/23/24 2. A Plastic Container of sliced Bologna had no label and was not dated. 3. A Plastic Container of sliced deli ham had no label and was not dated 4. A Plastic Container of Sour Cream had no label and was not dated 5. A Plastic Container of canned sliced apple with a use by date 5/23/24 6. A Plastic Containers of mashed Potato with a use by date 5/26/24 Observation…
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 before2024-05-31 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 6 residents reviewed for medications (Resident #67). The facility did not administer Resident #67's Divalproex Sodium (medication used to treat certain types of seizures, to treat manic episodes of bipolar disorder, and to prevent migraine headaches) as per pharmaceutical recommendation . These failures could place residents at risk of experiencing side effect of medications which could result in the exacerbation of their medical conditions and a decline in health status. The findings included: Resident #67 Record review of the face sheet dated 05/31/24, for Resident #67 revealed that the resident was admitted to the facility on [DATE]. The resident was an [AGE] year old female and had diagnoses of Parkinson's disease without…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-12 · tag F0622 — isolatedNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
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 the discharge was documented in the resident's medical record and appropriate information was communicated to the receiving health care institution or provider for 1 (Resident #1) of 18 residents reviewed for discharge. The facility failed to have the resident's physician document their discharge and all other necessary information in the medical records. This failure could place residents at risk of not getting the necessary care and services in a new facility to meet their physical and psychological needs. The findings were: Record review of Resident #1's face sheet revealed a [AGE] year-old who was initially admitted to the facility on [DATE] and discharged on 2/28/2024. Resident #1's medical diagnoses included Alzheimer's disease, Type 2 Diabetes Mellitus, Generalized Anxiety Disorder, Bipolar Disorder (severe), Depression, schizoaffective disorder (bipolar type), and unspecified dementia (unspecified severity, with other behavioral…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-12 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 interview and record review, the facility failed to send a copy of the discharge notice to the Office of the State Long-Term Care Ombudsman and failed to record the reasons for transfer or discharge in the resident's medical record for 1 (Resident #1) of 18 residents reviewed for discharge. The facility failed to notify the Ombudsman of Resident #1's discharge status after hospitalization. This failure could place residents at risk of being improperly discharged and not having access to available advocacy services, discharge/transfer options, and the appeal process. The findings were: Record review of Resident #1's face sheet revealed a [AGE] year-old who was initially admitted to the facility on [DATE] and discharged on 2/28/2024. Resident #1's medical diagnoses included Alzheimer's disease, Type 2 Diabetes Mellitus, Generalized Anxiety Disorder, Bipolar Disorder (severe), Depression, schizoaffective disorder (bipolar type), and unspecified dementia (unspecified severity, with other behavioral…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-03-17 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for the facility only kitchen, in that: The facility failed to ensure: One food item in the freezer was not secured in package. Several food items in the refrigerator were not secured in package. Several food items in the refrigerator were not labeled/had a use-by date. These failures have the potential to affect all residents who ate food from the facility's kitchen placing them at risk of foodborne illness. Findings included: During an observation of the kitchen on 3/14/23 at 6:40 AM the following was noted: Freezer: a. Frozen turkey breakfast patties in a plastic bag and box unsecured. Refrigerator: a. Sauce later identified as jelly in a plastic box unlabeled and unsecured in refrigerator. b. Previously used ham in Ziplock bag unsecured in refrigerator. No use by date. c. Spoiled leaves on top of the lettuce box and around edible lettuce. d. Chopped onions and peppers in plastic containers…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-03-17 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, which included procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, for 3 of 4 medication carts (100-200 Hall Medication Nurses Cart and 300-400 Hall Nursing Cart,100 and 4 00 hall medication aide cart) reviewed for pharmacy services. - The facility failed to discard an expired medications located in the 300-400 Hall Medication Nurse Cart. - The facility failed to ensure accurate count of control medications in the locked box in 100 - 400 Hall Medication Aide Cart. - The facility failed to discard an expired medications and store medication in it's original packet located in the 100 and 200 hall nurse's medication cart. These failures could place residents at risk of not receiving the therapeutic benefit of medications adverse reactions to medications and/or drug diversion. Findings include: During an observation on 03/15/23 at 2:00 p.m., the 300 - 400 Hall Medication Nurse Cart revealed the following 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.
- Potential for harm · Ecited before2023-03-17 · 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 did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 7 of 8 Staff (Housekeeper F, LVN B, and CNA C, Treatment Nurse, Housekeeping supervisor, Laundry Aide E) reviewed for infection control. 1. The facility failed to ensure Laundry Aide E followed proper use of PPE and infection control procedure while picking dirty linen from 400 hall to 200 hall. 2. The facility failed to ensure Housekeeper F followed proper use of PPE and infection control procedure while picking up trash from residents' rooms in 400. 3. The facility failed to ensure proper infection procedure when clean linen was stored in 400 hall clean linen closet. 4. The facility failed to ensure the Housekeeping Supervisor demonstrated how to perform hand hygiene properly. 5. The facility failed to ensure the Treatment Nurse proper infection control procedure during wound care for Resident #1. 6. The facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-17 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the residents' right to privacy during personal care for 2 of 3 residents (Resident #1 and Resident #175) reviewed for privacy in that: -The facility failed to ensure the Treatment Nurse and CNA C provided privacy during wound care for Resident #1. -The facility failed to ensure the Treatment Nurse and RA D provided privacy during wound care for Resident #175. These failures could place residents at risk of having their bodies exposed to the public, resulting in low self-esteem and a diminished quality of life. Findings included: Record review of Resident #1's face sheet revealed 58 years - old female was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnose were non- pressure chronic ulcer buttock with unspecified severity, Cellulitis of buttock, dementia, and diabetes mellitus Record review of Resident #1's quarterly MDS dated [DATE] indication BIMS (Brief Interview for Mental Status) of 00 revealed severe…
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 before2023-03-17 · 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 ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for two (Resident #1, and Resident #175) out of four residents reviewed for ADLs, in that: The facility failed to provide personal hygiene to Resident #1 and Resident #175, which resulted in Resident #1 toenails being overgrown and Resident # 175 feet being dry and having patches of dry skin. These deficient practices placed residents at risk of a decline in hygiene, at risk of skin breakdown, and reduced feelings of self-worth. Findings included: Resident #1 Record review of Resident #1's face sheet revealed 58 years - old female was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnose were non- pressure chronic ulcer buttock with unspecified severity, Cellulitis of buttock, dementia, and diabetes mellitus Record review of Resident #1's quarterly MDS dated [DATE] indication BIMS (Brief…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-17 · 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 interview and record review the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public for 1 of 3 residents (Resident #19) reviewed for environment. 1. The facility failed to monitor resident during smoke breaks. These failures could place residents at risk for accidental fire hazard. Findings Include: Record Review of Resident #19's Facesheet dated 03/16/23 revealed resident is a [AGE] year-old male who was admitted to the facility on [DATE]. Resident's diagnosis are atherosclerotic heart disease of native coronary artery without angina pectoris (restriction of oxygen to the heart), hyperlipidemia (high cholesterol), unspecified, essential (primary) hypertension (high blood pressure), aortic ectasia (blood flowing into the heart in the unintended direction, causing a risk for strokes), unspecified site, history of falling, dysarthria and anarthria (motor speech disorder), undifferentiated schizophrenia, other cerebrovascular disease (a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-17 · 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 received appropriate treatment and services to prevent urinary tract infections for one (Resident #1) of 2 residents observed for indwelling urinary catheters. LVN B failed to provide appropriate care for Resident #1 during Foley catheter care. This failure could affect residents, who were incontinent or had a catheter, and placed them at risk for urinary tract infection, discomfort, skin breakdown and decreased quality of life. Findings include: Record review of Resident #1's face sheet revealed 58 years - old female was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnose were non- pressure chronic ulcer buttock with unspecified severity, Cellulitis of buttock, dementia, and diabetes mellitus Record review of Resident #1's quarterly MDS dated [DATE] indication BIMS (Brief Interview for Mental Status) of 00 revealed severe impaired. It further revealed the resident was extensive to totally dependent…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-17 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that a resident fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings, for 1 (Resident #175) of 1 resident that was reviewed for feeding tubes, in that: -The facility failed to ensure LVN B appropriately verified placement and amount of fluid to be used for Resident #175 during medication administration and unclogging the feeding tube. This failure could place residents at risk for adverse reactions, inadequate therapy, and a decreased quality of life. Finding include: Record review of Resident #175 's face sheet revealed a 64 year - old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses were metabolic encephalopathy(a problem in the brain), protein - calorie malnutrition(reduced availability of nutrients lead to changes in body composition and function), acute kidney failure (stop working and are not able to remove waste and extra water from…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-17 · 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
Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were secured and stored properly for one of six medication carts (400 Hall Nurse Medication Cart) reviewed for drug storage. - LVN B failed to ensure 400 hall Nurse medication cart was locked when left unattended on 03/16/23. - LVN B failed to ensure a bottle of Aspirin was left on top of the 400 hall Nurse medication cart when left unattended. These failures could place residents at risk for possible drug diversions or accidental ingestion. Findings include: During an observation and interview on 03/16/23 at 7:40 a.m. revealed, LVN B left the 400-nurse medication cart unlocked and all the drawers easily opened. She also left a bottle of aspirin on top the cart while administering medication in a Resident's room. There were several residents and visitors, and staff walked up and passed the nurse medication cart in the hallway. During an interview on 3/16/23 at 8:18 a.m., LVN B said she did not realize she left the medication cart unlocked and a bottle 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.
“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
$8,412 in federal fines across 1 penalty.
- $8,412 — penalty dated 2025-07-09
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| SWEENY HOSPITAL DISTRICT | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; TRUSTEE OF THE SNF; ADP OF THE SNF | 100% | since 05/01/2021 |
| PARK, KELLY | Individual | CORPORATE OFFICER | — | since 05/01/2021 |
| RIDDLE, CIARA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/01/2025 |
| KLAUS, BART | Individual | ADP OF THE SNF | — | since 05/29/2025 |
CMS files one row per role, so the 7 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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 675996. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-09, 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.