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Copperas Cove Nursing & Rehabilitation

607 W. Ave. B, Copperas Cove, TX 76522 · For profit - Corporation · 123 certified beds · (254) 547-1033 Medicare & Medicaid certified

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1 immediate-jeopardy citation1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$24,242 in federal fines
Insights

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

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $24,242 in federal fines (most recent 2025-07-30)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • its facility-reported quality-measure rating is low (2/5)
  • nursing-staff turnover (61%) runs well above the national median (45%)

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

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

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
601 S Main St · (254) 518-4673 · Call to confirm hours
Pharmacy
Walgreens0.7 mi
527 E Business 190 · (254) 547-1630 · Call to confirm hours
Grocery
190 Highway Ave
Park
1206 W Avenue B · (254) 542-2719 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 3 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 held steady at 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.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased16.3%15.8%15.4%typical
Long-stay residents who lose too much weight11.5%3.0%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection2.7%0.8%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms1.6%2.4%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury3.8%3.3%3.3%worse
Long-stay residents whose ability to walk worsened7.4%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication10.5%18.0%18.9%better
Long-stay residents given the seasonal flu vaccine98.6%98.0%95.3%typical
Long-stay residents with pressure ulcers6.9%3.8%4.7%worse
Long-stay residents with worsening bladder/bowel control18.0%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table16.8%9.6%17.1%typical
Short-stay residents who newly got an antipsychotic medication4.6%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine89.4%88.0%79.4%better
Short-stay residents rehospitalized after admission34.2%25.7%22.6%worse
Short-stay residents with an outpatient ER visit31.0%12.3%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.842.171.67typical
Long-stay outpatient ER visits per 1,000 resident days4.762.061.80worse

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.

10.5%U.S. median 10.7%
Went back to hospital
0.18U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy

Therapy staffing: this home’s payroll records show 0.18 therapist hours per resident per day in 2026Q1 — more than 19% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.5%CMS range 6.7–15.410.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified90.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot 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 dischargenot 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.2%CMS range 3.8–14.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.021.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.16
RN hours/ resident / day
0.82
LPN hours/ resident / day
1.90
Aide hours/ resident / day
2.88
Total nurse hours/ resident / day
0.14
RN hoursweekends
60.9%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 123 beds and averages 75.3 residents a day — about 61% occupied, or roughly 48 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.88 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.16 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.90 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 2.68 hrs/resident/day on weekends vs 2.96 on weekdays — 10% thinner on weekends. RN hours go from 0.17 to 0.14 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 61% is well above the national median of 45%.

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

4
deficiencies at the latest standard inspection (2025-11-26)
9
at the previous standard inspection (2024-09-19)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

28 citations, most serious first. The 12 most serious are shown; the remaining 16 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2025-07-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for one (Resident #1) of three residents reviewed for accidents and hazards. The facility failed to ensure CNA A did not provide personal care for Resident #1 without another staff member (which he required) on 07/27/25. She yanked on his right arm when attempting to roll him to his side, and he heard a pop. He was in excruciating pain and was subsequently diagnosed with a shoulder sprain at the hospital. The noncompliance was identified as PNC. The IJ began on 07/27/25 and ended on 07/29/25. The facility had corrected the noncompliance before the survey began. This deficient practice placed residents at risk of pain, injury, and hospitalization. Findings included:Review of Resident #1's undated face sheet reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Immediate jeopardy · J2024-10-16 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to provide the necessary care and service to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing for 1 (Resident # 1) of 6 (Resident's 2.3.4.5.amd 6) residents reviewed for following hospital discharge orders. The facility failed to follow hospital discharge orders for follow up with Urology secondary to a urethral stent (a thin tube placed between the kidney and bladder to help urine flow) placement on 4/26/2024. On 10/12/24 at 5:10 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 10/16/24, the facility remained out of compliance at a scope of Isolated and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure resulted in Resident # 1 with worsening medical condition and Hospitalization. Finding included: Review of Resident # 1's face sheet reflected a [AGE] year old male…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-04-13 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrates they were unavoidable, and a resident with pressure ulcers received necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 5 Residents (Resident #1) reviewed for quality of care. The facility failed to complete wound care treatment for Resident #1 on 01/03/2026, 01/30/2026, 02/05/2026, 02/07/2026, 02/08/2026. This failure could place residents at risk of rapid wound deterioration.Findings included:A record review of Resident #1's face sheet, dated 04/11/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included pressure ulcer of sacral region,(shield -shaped bone at the base of the lumbar spine connecting 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-04-13 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for complete and accurate records.The facility failed to ensure Resident #1's wound care cleaning was documented completed in PCC for 01/10/2026, 01/25/2026, 02/14/2026, 02/17/2026, 02/19/2026, 02/21/2026, 02/23/2026, 02/26/2026, 03/06/2026, 03/07/2026, 03/10/2026, 03/11/2026, 03/13/2026, 03/16/2026, 03/17/2026, 03/22/2026, 03/23/2026, and 03/30/2026.This failure could place residents of staff not knowing whether treatment and services were provided for. Findings include:A record review of Resident #1's face sheet, dated 04/11/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included pressure ulcer of sacral region,(shield -shaped bone at the base of the lumbar spine connecting…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-12-10 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodations of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 3 of 8 residents (Residents #1, #2, & #3) reviewed for resident rights.The facility failed to ensure Residents #1, #2, & #3's call lights were within reach on 12/09/2025.This failure could place residents at risk of their needs not being metFindings include:Record review of Resident #1's admission record, dated 12/10/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: Epilepsy (a brain disorder causing recurrent seizure), Alzheimer's disease (progressive brain disorder that slowly destroys memory and thinking skills), and muscle weakness (loss of strength in muscles making it difficult to move or perform physical task).Record…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-11-26 · tag F0732 — pattern
    Post nurse staffing information every day.
    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 nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 1 of 1 days reviewed (9/23/2025) for nurse staffing posting.The facility failed to post accurate daily staffing information on 9/23/2025. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts.Findings included:During an observation on 9/23/2025 at 12:45 PM, the daily staffing census information was posted on the wall outside the DON office dated 8/21/2025; 8/22/2025; 8/26/2025, 8/27/2025; 8/29/2025.During an interview on 9/25/2025 at 11:30 a.m., the DON stated it was her job or the ADON to post the staffing on the daily basis. The negative outcome would be no one knows what the staffing was for the day.During an interview on 9/25/2025 at 11:35 a.m., the ADON stated it was her job or the DONs job to post the daily staffing. She stated nobody would know what the staffing…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-11-26 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 need of each resident. On 2 of the 4 medication carts reviewed the facility failed to establish a system of record of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation at each shift change. This failure could place residents at risk of drug diversions and could result in diminished health and well-being.Findings Include: Record review of the change of shift narcotic count sheets for the medication cart on B Hall reflected missing documentation on the Narcotic count sheet for the following:*9/17/2025 1st shift on-coming and off -going shifts, *9/18/2025 1st shift off-going,*9/22/2025 1st shift on-coming and off- going shift, and *9/23/2024 1st shift on-coming and off-going. Record review of Narcotic count sheet for the mediation cart on D hall reflected missing documentation for 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-11-26 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure drugs and biological were stored under proper temperature for 1of 1 Medication Rooms reviewed for medication storage. The facility failed to ensure the correct temperature for the storage of refrigerated medications for 4 days in Medication room [ROOM NUMBER]. The facility failed to check the medication storage temperature for 10 of 23 days for the month of September 2024.This failure could place residents receiving medication at risk for lack of drug efficacy.Findings included:During an observation and record review of the Refrigerator Temperature Log for the month of September 2025 in Medication room [ROOM NUMBER] on 09/24/2025 at 10:19AM temperature readings were below 36 degrees Fahrenheit for 4 days.*9/4/2025 34 degrees F*9/13/2025 32 degrees F*9/14/2025 30 degrees F*9/15/2025 32 degrees F The out-of-range temperatures read from 30 degrees Fahrenheit to 34 degrees Fahrenheit. The temperature of the medication refrigerator 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-11-26 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen reviewed for food service safety. The facility failed to ensure food safety by not consistently monitoring, discarding expired food, maintaining sanitary kitchen. These failures can place residents at risk for foodborne illness. Findings included:Observation in the kitchen on 9/23/2025 at 9:15 AM of refrigerator #1 reflected a bag of Pepperoni was not sealed. Observation in the kitchen on 9/23/2025 at 9:20 AM of refrigerator #2 reflected the Ready Care Thickening water that had an expiration date of 4-9-2025. Observation in the kitchen on 9/23/2025 at 9:26 AM of refrigerator #3 reflected the Sour cream and ketchup in individualized containers were in a zip-lock bag dated 9/17/25 with no expiration date. Observation in the kitchen and interview on 9/23/2025 at 9:35 AM revealed the one pantry in the kitchen reflected a bag of Hot dog buns opened labeled date of 9-12-2025, and the DM said that bread has 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-22 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to provide the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 (Resident #2) of 4 residents reviewed for resident rights.The facility failed to follow their policies and procedures and provide full-time translation or interpretation services to Resident #2, a [NAME] speaking resident.This failure could place residents at risk of miscommunication between the resident and staff, lead to misunderstandings about a resident's medical condition and treatment options, and improper care or inappropriate treatments or prescriptions.Findings include:Record review of Resident #2's face sheet, dated 11/14/25, revealed a seventy-four-year-old female who was admitted to the facility on [DATE]. Her admitting diagnoses included Alzheimer's disease (progressive decline in episodic memory, with…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-22 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    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 interviews, the facility failed to respect a resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 1 (Resident #1) of 5 residents reviewed for resident rights.The facility failed to obtain a valid DNR for Resident #1 which resulted, on [DATE], in Resident #1 receiving CPR when she was found unresponsive. This failure could place residents at risk of their rights to refuse or discontinue treatment being disrespected, being resuscitated against their wishes or placed on life support.Findings included:Record review of Resident #1's face sheet, dated [DATE], revealed an eighty-four-year-old female who was admitted to the facility on [DATE]. Her admitting diagnoses included adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-22 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide 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, record reviews, and interviews, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for one (Resident #1) of 7 (seven) residents reviewed for weight loss.The facility failed to follow its procedures and provide effective interventions to prevent weight loss in Resident #1, who had a 10.39% weight loss between 10/09/25 and 11/03/25. Resident #1 was not weighed when she was admitted to the facility on [DATE]. Resident #1 was not weighed weekly x 4 weeks after her admission to the facility. Nutritional supplements were recommended by the RD on 10/15/25. They were ordered 11/14/25. Resident #1 died on [DATE].This failure could place residents at risk of dehydration, malnutrition, functional decline and death.Findings included:Record review of Resident #1's face sheet,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · Ecited before2025-07-09 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the resident's right to be free from abuse, neglect, misappropriation of resident property and exploitation for three of five residents (Resident #1, Resident #2, and Resident #3 ) reviewed for drug diversion. 1. The facility failed to ensure LVN A did not take 100 (one hundred) Torsemide 100 mg tablets prescribed for Resident #1.2. The facility failed to ensure LVN A did not take 100 (one hundred) Torsemide 100 mg tablets prescribed for Resident #2.3. The facility failed to ensure LVN A did not take 30 (thirty) Torsemide 100 mg tablets prescribed for Resident #3. These failures could place residents at risk of misappropriation, medication errors and compromised health conditions. Findings include: Record review of the facility's self-report intake, dated 5/5/2025, revealed the following: Narrative of The IncidentSame nurse entered orders for three different residents for the same medication, Torsemide. The medications were then discontinued…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-02-12 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen and food sanitation. 1. The facility failed to ensure food in the refrigerator was properly sealed from air-borne contamination. 2. The facility failed to ensure food stored in 1 of 1 reach in freezer and 2 of 2 reach in refrigerators were labeled and dated with use by date. These failures could place residents at risk for food contamination and foodborne illness. Findings Included: Observations on 02/12/25 at 09:32 AM in the facility's only kitchen revealed: 1 of 1, 3-door reach in refrigerator contained: - 1 large metal tray of cheesecake was not covered or sealed from air-borne contaminants or labeled with use by date. - 1 large metal tray of gelatin, 1 medium plastic container of diced tomatoes, 1 medium plastic container of grape jelly, 1 medium plastic container of caramel, 1 medium plastic container of pumpkin filling, 1 medium plastic container of ketchup, 2…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-12 · tag F0622 — isolated
    Not 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 record review and interviews the facility failed to ensure that one (1) resident (Resident #1) of eight residents reviewed for transfer or discharge had the required documentation in the resident's medical record made by the physician and failed to provide information to the receiving health care provider for a safe and effective transition of care. The facility discharged Resident #1 on 9/18/2025 without physician documentation in the EMR and without providing any clinical information for continuity of care to the receiving provider. This failure could put residents at risk for inappropriate discharge from the facility and cause psychological harm. The findings included: Review of Resident #1's Face Sheet dated 2/7/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included acute kidney failure, anemia (low iron count in the blood), anxiety disorder, sleep disorder, chronic pain syndrome, hypertension (high blood pressure), and traumatic brain injury. Review…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-09-19 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 7 (room [ROOM NUMBER], #2, #3, #4, #5, #6, and #7) of 20 resident rooms reviewed for cleanliness and sanitization. The facility failed to ensure that Resident Rooms #1, #2, #3, #4, #5, #6, and #7 were thoroughly cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings included: An observation on 09/17/24 at 10:38 AM of Resident room [ROOM NUMBER] reflected the windowsill had black dirt particles on it. The air vent on the upper portion of the wall had thick dust between the vents. An observation on 09/17/24 at 10:44 AM of Resident room [ROOM NUMBER] reflected the air vent on the upper portion of the wall had thick dust between the vents. An observation on…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-09-19 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, 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 set forth 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 a resident for three (Resident #10, Resident #11, and Resident #52) of eight residents reviewed for Care Plans. The facility failed to ensure Residents #10, #11, and #52 were care planned for oxygen administration. This failure could place the residents at risk of not receiving the necessary care and services. Findings included: Review of Resident #10's Face Sheet, dated 09/18/2024, reflected the resident was a [AGE] year-old male admitted on [DATE]. Resident #10's pertinent diagnoses included chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and history 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-09-19 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide 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 observations, interviews, 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 residents' goals and preferences for six (Resident #10, Resident #11, Resident #52, Resident #61, Resident #68, and Resident #222) of twelve residents reviewed for Respiratory Care. 1. The facility failed to ensure that Resident #10, #11, #52, and #68's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) were properly stored. 2. The facility failed to ensure that Resident #61's CPAP (continuous positive airway pressure: machine use to deliver pressurized air through a mask to keep airways open) was stored properly. 3. The facility failed to ensure that Resident #222's nebulizer (machine that turns liquid medication into a mist and breathed directly into the lungs) was stored properly. The facility failed to provide humidified…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-09-19 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. 1. The facility failed to ensure foods in the refrigerator were properly sealed from air-borne contaminations. 2. The facility failed to ensure a pitcher containing juice, located in the refrigerator, was cleaned. 3. The facility failed to ensure the ice scoop holder, located in the kitchen area, was cleaned. 4. The facility failed to ensure the food stored in the refrigerator and freezer were labeled with the use by date. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings included: Observations on 09/17/24 from 8:30 AM to 8:38 AM in the facility's only kitchen reflected: One large zip locked bag of frozen fries did not have a use by date. One large zip locked bag of frozen chicken parts did not have a use by date. One large zip…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-09-19 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #66 and Resident #68) of eight residents observed for Infection Control. 1. The facility failed to ensure that CNA A performed hand hygiene while providing incontinent care to Resident #66. 2. The facility failed to ensure that LVN F performed hand hygiene during Resident #66's wound care. 3. The facility failed to ensure that CNA C performed hand hygiene while providing incontinent care to Resident #68. These failures could place the residents at risk of cross-contamination and development of infections. Findings included: 1. Review of Resident #66's Face Sheet, dated 09/18/2024, reflected resident was an [AGE] year-old male admitted on [DATE]. One of Resident #66's diagnoses was unspecified pain. Review 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-19 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure the right to receive services in the facility with reasonable accommodation of resident needs and preferences for 2 (Resident #41 and Resident #58) of 14 residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #41's room was in a position that was accessible to Resident #41. The facility failed to ensure the call light system in Resident #58's room was in a position that was accessible to Resident #58. This failure could place Resident #41 and Resident #58 at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: Review of Resident #41's Face Sheet, dated 09/19/2024, reflected that Resident #41 was an [AGE] year-old male admitted [DATE]. Resident #41 was diagnosed with Alzheimer's disease (disorder that causes the brain to shrink and brain cells to eventually die) and heart failure (heart does not pump as well…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-19 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide the right to personal privacy during medical treatment and personal care for two (Resident #1 and Resident #10) of thirteen residents reviewed for privacy. 1. The facility failed to ensure LVN E would close Resident #1's door while administering the resident's bolus feeding (method of tube feeding that delivers large amount of formula over a short period of time). 2. The facility failed to ensure CNA B and CNA D would close Resident #10's door while transferring the resident. These failures could place the residents at risk of not having their right to personal privacy maintained. Findings included: 1. Review of Resident #1's Face Sheet, dated 09/18/2024, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #1's pertinent diagnoses included cerebral palsy (neurological condition that affects muscle movement) and dysphagia (difficulty in swallowing). Review of Resident #1's Quarterly MDS Assessment,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-19 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure residents with pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown or pressure ulcers for one (Resident #66) of three resident reviewed for pressure ulcers. The facility failed to ensure LVN F cleaned the pressure ulcer on Resident #66's right heel from inside to outside. This failure could place the residents with pressure ulcers at risk for worsening of existing pressure ulcers. Findings included: Review of Resident #66's Face Sheet, dated 09/18/2024, reflected the resident was an [AGE] year-old male admitted on [DATE]. One of Resident #66's diagnosis was type 2 diabetes mellitus (body has higher sugar level) without complications. Review of Resident #66's Quarterly MDS Assessment, dated 08/13/2024, reflected the resident was cognitively intact with a BIMS score of 14. The Quarterly MDS Assessment indicated 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 1 (Resident #1) of 4 residents reviewed for accident prevention. The facility failed to obtain physician orders or a physician assessment as of 09/18/24 for Residents #1 for the usage of a scoop mattress prior to installing the mattress to assist in fall prevention. This failure could prevent residents from having an environment that was free and clear of accidents and hazards. Findings included: Record review of Resident #1's Face Sheet, dated 09/18/2024, reflected she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included cerebral palsy (congenital disorder), lack of coordination, and abnormal involuntary movements. Record review of Resident #1's Quarterly Minimum Data Set (MDS) dated [DATE] reflected, she had a Brief Interview for Mental Status (BIMS) score of 99 (severe cognitive impairment) and for ADL care it reflected…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-15 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews 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 one (Resident #1) out of five residents reviewed for showers. The facility failed to provide showers to Resident #1, her preferred method of bathing. Resident #1 was administered two (2) showers, her preferred method of bathing, from her admission on [DATE] until 07/15/2024. This failure placed residents at risk of a decline in hygiene, at risk of skin breakdown, level of satisfaction with life, and feelings of self-worth. Findings included: Review of Resident #1's face sheet dated 07/12/2024 reflected a [AGE] year-old female resident admitted on [DATE], diagnosed with neuromuscular dysfunction of bladder and type 2 diabetes. Review of Resident #1's quarterly MDS , dated 04/18/2024, reflected a BIMS score of 15, indicating no cognitive impairment. Section G (Functional Status) reflected she required extensive assistance…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-07-19 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 for one of one kitchen reviewed for sanitation. The DM failed to ensure all items were dated when they were opened. The DM failed to properly store beverages. CK B failed to reheat food to the temperature required for serving. These failures placed residents at risk of foodborne illness. Findings included: During an interview and observation of the kitchen on 7/17/2023 at 8:22 a.m., the reach-in refrigerator contained an opened container of mayonnaise dated 6/30/2023, an opened container of sweet and sour sauce dated 6//09/2023, an opened container of tartar sauce dated 5/19/2023, and an opened container of mustard dated 6/9/2023. CK B stated all opened items should have two dates-a received date and an opened date. CK B stated if it were an opened date, the container would say opened. CK B stated the dates on the condiments were…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-19 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for two of 20 residents (Residents #24 and 27) reviewed for activities. Residents #24 and 27, who spent most of their time in their rooms, did not have a program of activities based on their needs and preferences. This failure placed residents at risk of depression and diminished quality of life. Findings included: Review of the undated face sheet for a resident number 24 reflected an [AGE] year old female admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, reduced mobility, need for assistance…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-19 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident received food that accommodates resident allergies, intolerances, and preferences for one of eight residents (Resident #169) reviewed for food preferences. Resident #169 was not given any meat or meat alternative in her meals for her first fourteen meals at the facility. This failure placed residents at risk of weight loss, slow wound healing, and a lack of enjoyment. Findings included: Review of the undated face sheet for resident number 169, reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of dementia and hypertension. Review of MDS assessments for Resident #169 reflected that none had yet been completed. Review of the baseline care plan for Resident #169 dated 07/14/23 reflected the following: Resident is here for LTC. Able to make basic needs known. Mechanical soft diet and only eats fish for meat on Fridays. Review of nursing progress notes for Resident #169 reflected the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$24,242 in federal fines across 2 penalties.

  • $15,177 — penalty dated 2025-07-30
  • $9,065 — penalty dated 2024-09-19

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

Part of a chain

This home belongs to GULF COAST LTC PARTNERS — 20 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 52.4-1.4 vs chain
Health inspection 2 of 53.0-1.0 vs chain
Staffing 1 of 51.6-0.6 vs chain
Quality measures 2 of 52.6-0.6 vs chain
The other 19 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 / managerTypeRoleSince
COPPERAS COVE PROPERTY, LLCOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 01/01/2023
MURRELL, EDWARDIndividualCORPORATE OFFICERsince 01/01/2023
COPPERAS COVE LTC PARTNERS,INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2023
BERGERON, BOBBYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2023
NICHOLSON, LOUISIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2023
GREEN, NADELINEIndividualADP OF THE SNFsince 02/05/2024
SYED, ASIFIndividualADP OF THE SNFsince 12/01/2024

CMS files one row per role, so the 8 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

$4.8M
Net patient revenuemost recent cost report
-2.9%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 56%Medicare 6%Other / private 38%

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

$212per resident / day
operating cost
$6,458per month
≈ monthly operating cost
$206per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in TX

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.

Typical monthly cost in Texas
$5,627/mo
Nursing home (semi-private)
$7,604/mo
Nursing home (private)
$5,666/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 455515. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-26, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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