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Hill Country Heights

810 Industrial Ave, Copperas Cove, TX 76522 · For profit - Limited Liability company · 96 certified beds · (254) 547-9552 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 immediate-jeopardy citation$12,356 in federal fines
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
Worth asking about
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $12,356 in federal fines (most recent 2024-06-23)
  • its payroll-based staffing rating is low (2/5)

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

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

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
TSO Cove0.5 mi
98 Cove Terrace Shopping Ctr · (254) 542-2020 · Call to confirm hours
Pharmacy
806 E Avenue D · (254) 547-4146 · Call to confirm hours
Grocery
804 E Highway 190 · (254) 547-6333 · Call to confirm hours
Park
1204 Amthor Ave · (254) 542-2719 · Typically dawn to dusk
Place of worship
801 Industrial Ave · (254) 542-3211

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased12.2%15.8%15.4%better
Long-stay residents who lose too much weight3.2%3.0%5.4%better
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 infection0.0%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.0%2.4%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.0%3.3%3.3%check this — see note marked star below the table
Long-stay residents whose ability to walk worsened7.5%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication13.5%18.0%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers3.4%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control7.8%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table6.7%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine92.4%88.0%79.4%better
Short-stay residents rehospitalized after admission23.7%25.7%22.6%typical
Short-stay residents with an outpatient ER visit26.8%12.3%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.702.171.67worse
Long-stay outpatient ER visits per 1,000 resident days1.792.061.80typical

* 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.

50.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 87 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

50.1%U.S. median 51.5%
Got home and stayed home
10.8%U.S. median 10.7%
Went back to hospital
58.1%U.S. median 56.6%
Met the expected recovery
0.34U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.16hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 58.1% 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 31 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 0.34 therapist hours per resident per day in 2026Q1 — more than 57% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 17% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF50.1%CMS range 39.6–58.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.8%CMS range 7.3–15.710.7%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 discharge58.1%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge51.6%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge51.6%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 worsened1.9%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 hospitalization9.8%CMS range 5.5–15.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.271.02Oct 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

0.44
RN hours/ resident / day
0.76
LPN hours/ resident / day
2.27
Aide hours/ resident / day
3.48
Total nurse hours/ resident / day
0.36
RN hoursweekends
42.1%
Total nursing turnover
22.2%
RN turnover

How full it usually is: this home is certified for 96 beds and averages 75.7 residents a day — about 79% occupied, or roughly 20 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.478 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.44 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.27 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 3.05 hrs/resident/day on weekends vs 3.65 on weekdays — 16% thinner on weekends. RN hours go from 0.48 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 42% is about the same as the national median of 45%.

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

Inspection trend

4
deficiencies at the latest standard inspection (2026-05-21)
3
at the previous standard inspection (2025-03-20)

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.

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.

23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2024-06-23 · 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 observation, record reviews and interviews, the facility failed to ensure a resident's environment remained free of accident hazards and received adequate supervision and assistance devices to prevent accidents for 1 of 13 residents (Resident #1) reviewed for transfers in that: CNA A failed to provide adequate supervision and transfer assistance for Resident #1 in the shower resulting in Resident #1 falling and having an open right ankle fracture with bleeding. Resident #1 had to be hospitalized and required surgical intervention. The facility failed to update the Kardex and POC to reflect current safe transfer status requirements for Resident #1 and 12 other residents. The facility failed to ensure CNAs were knowledgeable on how to locate the Kardex to determine if 1 or 2 staff were required to safely transfer/assist a resident. An IJ was identified on 06/21/24. The IJ Template was provided to the facility on [DATE] at 04:25 PM. While the IJ was removed on 06/23/2024, the facility remained out 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-05-21 · 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, 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. 1.The facility failed to ensure sanitation practices (ensuring trash receptacles were securely covered, ensuring kitchen floors were free from debris, ensuring kitchen utensils were free of dried debris, ensuring kitchen utility cart was debris free, and ensuring kitchen shelving was debris free)2.The facility failed to label and date all food items in the kitchen. These failures could place residents at risk of foodborne illness. During an observation on 5/19/26 at 6:13 am, of the facility's kitchen revealed: -Utility cart next to steam table had dried food debris and spilled dried liquids of red and brown color on all 3 levels of the utility cart.-microwave revealed the inside top of the microwave to have dried food debris on the ceiling of the microwave.-overhead shelf near cooktop revealed a container of [NAME] Krispie cereal labeled cereal and dated…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-21 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 1 resident (Resident #20) of 6 residents reviewed for care plans. The facility failed to ensure Resident #20 received her divided plate and small 4 oz. cups with a straw at mealtimes and was included in her care plan. These failures could affect residents and put them at risk of not receiving care and services to meet their needs.Record review of Resident #20's face sheet dated 05/20/2026, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: Cerebral palsy (a condition caused from damage or abnormal development to a part of the brain which is responsible for muscle movement and leads to movement disorders and may result in developmental delays and sensory impairments), unspecified 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-21 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    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 observation, interview, and record review the facility failed to ensure a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents goals and preferences for 1 of 1 resident (Resident #7) reviewed for tracheostomy care. The facility failed to ensure ADNS LVN used aseptic technique (a procedure that healthcare providers use to prevent the spread of germs that cause infection) during tracheostomy care and tracheostomy suctioning for Resident #7 by not performing hand hygiene, placing barriers, performing proper suction depth procedures or using sterile equipment during care on 05/20/2026. This failure could place residents at risk for respiratory infections and respiratory distress.Findings included: Review of Resident #7's face sheet dated 05/21/2026 reflected a [AGE] year old female admitted to the facility on [DATE] with the following…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-21 · tag F0810 — isolated
    Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    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 provide special eating equipment and cups with straws for resident who need them for 1 of 6 (Residents #20) residents reviewed for special eating equipment. The facility failed to provide Resident #20's physician ordered divided plate and 4 oz cup with straw with lid for drinking on 05/20/2026. This failure could place residents at risk for harm by weight loss, diminished independence, and self-esteem.Record review of Resident #20's face sheet dated 05/20/2026, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: Cerebral palsy (a condition caused from damage or abnormal development to a part of the brain which is responsible for muscle movement and leads to movement disorders and may result in developmental delays and sensory impairments), unspecified severe protein-calorie malnutrition (condition where the body is not getting enough protein and calories leading to weight loss,…

    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 · E2025-12-08 · tag F0580 — failed to tell family and doctor about changes — pattern
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's health status (that is, a deterioration in health status in either life-threatening conditions or clinical complications), and need to alter treatment significantly for one (Resident #1) of six residents reviewed for notification of changes. The facility failed to notify the wound care provider when Resident #1's sacral region continued to develop new areas of MASD from 07/08/2025 to 08/22/2025. This failure could result in decreased continuity of care, and a delay in the treatment and services needed. Findings included: Review of Resident #1's face sheet dated 09/30/2025 reflected a [AGE] year-old female with an admission date of 05/12/2025 and discharge date of 09/26/2025 with diagnoses of cerebral infarction (condition where blood flow to the brain is interrupted leading to brain tissue damage), hypertensive heath and chronic kidney disease 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 · Ecited before2025-03-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    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 observation, interview and record review, the facility failed to ensure all assistive devices were maintained and free of hazards for four (Residents #13, #21, 48 and #221) of fifteen residents reviewed for essential equipment. The facility failed to properly maintain wheelchairs for Residents #13, #21, #48 and #221. These failures could place residents at risk for equipment that is in unsafe operating condition, which could cause injury. Findings included: Review of Resident #13's annual MDS assessment, dated 12/04/2024, reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Cerebral Infarction (stroke), generalized weakness, and hemiplegia/hemiparesis (loss of use arms and legs). Resident #13 had a BIMs score of 00 indicating she was severely cognitively impaired and unable to make decisions for herself. Section GG of the MDS reflected wheelchair mobility for locomotion. Review of the Resident #13's plan of care dated 12/04/2024 with updates reflected goals and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-20 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 (MA A) staff members and 2 of 4 residents (Residents #47, and #221) reviewed for infection control procedures. MA A failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #47 and #221. This failure could place residents at risk for cross contamination and infections. Findings included: Record review of Resident #47's quarterly MDS assessment, dated 01/25/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #47 had diagnoses which included: Diabetes (high blood sugar), and hypertension (high blood pressure). Resident #47 was cognitive and able to make decisions and required assistance of one staff for activities of daily living. 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-01-31 · tag F0804 — failed to serve food at safe, palatable temperature — widespread
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews , the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive and at a safe and appetizing temperature for residents who consumed foods orally from the only kitchen in the facility in that: 1. The facility failed to provide palatable food that was attractive or appetizing to residents' who complained the food was unidentifiable and did not taste good. 2. The test tray of the lunch meal foods were dry, bland, and cold. This failure could place residents at risk of decreased food intake, hunger, unwanted weight loss, and diminished quality of life. The findings included: 1. a. During a confidential interview and observation on 01/29/24 at 12:52 PM a resident stated she was not eating the unstuffed peppers being served and said, I do not eat anything I cannot look at and easily identify or know what it is. An observation of the resident's lunch plate revealed the served unstuffed peppers entrée was not touched by…

    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 · Fcited before2024-01-31 · 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

    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 1 of 1 kitchen reviewed for food and nutrition services. 1. The facility failed to ensure dry storage food was properly labeled and dated. 2. The facility failed to ensure dry storage items were sealed properly. 3. The facility failed to properly label and date items in the refrigerator and freezer. 4. The facility failed to ensure expired food was discarded. 5. The facility failed to ensure kitchen staff practiced proper hand hygiene and glove use. 6. The facility failed to ensure hairnets were worn while in the kitchen. These failures could place residents at risk for food contamination and foodborne illness. Findings included: During the initial tour of the kitchen on 01/29/24 at 08:49 AM the following was observed: 1. Baked beans were observed in a metal pan covered with saran wrap with use by date of 01/03/24. 2. Pie crust sealed in a clear bag with no label or date observed in the freezer. 3.…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-31 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of their quality of life for two (Resident #3 and Resident #39) of six residents reviewed for rights. 1. The facility failed to ensure Resident #3 catheter bag was covered when out of room. 2. The facility failed to provide dignity and respect for Resident #39 by not aiding a resident that required assistance in dressing. These failures placed the residents at risk of a decline of their sense of dignity, level of satisfaction with life, and feelings of self-worth. Findings included: 1. Review of Resident #3's face sheet, dated 01/31/2022, reflected a 70 -year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of: cognitive communication disorder (difficulty with any aspect of communication that is affected by disruption of cognition such as: attention, memory, organization, and problem…

    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
Show the remaining 12 citations
  • Potential for harm · D2024-01-31 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to develop and implement a baseline care plan for each resident within 48 hours of the resident's admission that included instructions for providing effective person-centered care for the resident and met professional standards of quality of care for 1 of 4 residents (Resident # 58) reviewed for care plans, in that: The facility failed to develop and implement a baseline care plan for Resident #58. This failure placed residents at risk of not having their immediate care needs met or not receiving continuity of care. Findings included: Record review of Resident #58's face sheet, dated 01/31/2024, reflected an [AGE] year old female was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus without complications ( a condition that happens because of a problem in the way the body regulates and uses sugar as fuel), chronic kidney disease, stage 4 ( kidneys are moderately or severely damaged and are not working as well as they…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-31 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident medical, nursing and mental and psychosocial needs for 3 (Resident # 3, 52 and 55) 16 residents reviewed for care plans. 1. The facility failed to ensure Resident # 3's Catheter was addressed on her care plan. 2. The Facility failed to ensure Resident # 52's care plan was updated by removing isolation when the resident no longer medically required it. 3. The facility failed to ensure Resident # 55's Fluid restriction and noncompliance with restrictions was on the care plan. This failure placed the resident at risk for not having their individual needs met in a timely manner and communicated to provide and could result in injury and a decline in physical well-being. Findings included. 1. Review of Resident #3's face sheet, dated 01/31/2022, reflected a 70 -year-old female admitted to the facility 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-31 · 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 observation, interview, and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for two of eight residents (Resident # 11 and Resident # 16) reviewed for quality of life. 1. The facility failed to ensure Resident #11's nails were trimmed. 2. The facility failed to ensure Resident #16's nails were cleaned. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings included: 1. Record review of Resident #11's face sheet, dated 01/31/2024 reflected an [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses included muscle weakness ( a lack of strength in muscles), cerebral infarction ( caused by impaired blood flow to the brain), chronic pain syndrome ( pain that lasts longer than three months), and cognitive communication deficit (difficulty with any aspect of communication…

    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 before2024-01-31 · 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 observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 2 (Resident # 6 and Resident # 22) of 8 reviewed for Quality of care. The facility failed to maintain the drainage bag to Resident # 6's surgical wound in a position that it could drain. The facility failed to obtain a physician's order for finger sticks for Resident # 22 who was on sliding-scale insulin. These Failures could put the residents at risk for infection, and risk for medical decline. Findings included: Review of Resident # 6's face sheet revealed an [AGE] year-old female, admitted to the facility on [DATE] and readmitted on [DATE], and 1/1/2024 with diagnoses that include Acute Cholecystitis (Inflammation of the Gallbladder), Malignant Neoplasm of Pancreas (A type of cancer that begins as a growth of cells in the pancreas), Diabetes mellitus due to underlying condition (elevated blood sugar due to a medical condition) 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-31 · 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 interviews and record review the facility failed to ensure residents maintained acceptable parameters of nutritional status for 1 resident ( Resident # 57) of 8 reviewed for accurate weights. The facility failed to establish a consistent method of weighing residents to ensure the accuracy of weight. for 1 resident (Resident # 57) of 8 reviewed for accurate weights. This failure put the residents at risk for undetected weight loss, malnutrition, medical complications poor quality of life. Findings included: Review of Resident # 57 face sheet revealed a [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that include Heart Failure ( a chronic condition in which the heart doesn't pump blood as well as it should), Acute Respiratory Failure with Hypoxia ( a condition where you don't have enough oxygen in the tissues in your body), Metabolic Encephalopathy ( an acute condition of global cerebral ( Brain) dysfunction in the absence of brain disease. ) 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-31 · tag F0697 — failed to manage pain — isolated
    Provide 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 interviews and record review , the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident reviewed for pain management (Resident #27), in that: RN C failed to assess and evaluate Resident# 27's existing pain and cause for pain in the administration of an opioid (narcotic). RN C failed to verify last administered dose of an opioid (narcotic) and available PRN pain medications putting the resident at risk for overmedication causing oversedation hypoxia oversedation respiratory failure. This failure placed Resident# 7 residents at risk for continued pain and adverse drug consequences. A record review of Resident# 27's face sheet dated 01/31/24 revealed he was admitted on [DATE] with a diagnosis of Hemiplegia and Hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side…

    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 · D2023-10-12 · tag F0694 — isolated
    Provide for the safe, appropriate administration of IV fluids for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to administer parenteral fluids consistent with professional standards of practice and in accordance with physician orders for two (Resident #1 and Resident #2) of two residents reviewed for parenteral fluids. 1. The facility failed to ensure RN A and LVN B stopped administration of TPN (nutrition administered intravenously through a large vein near the heart) which could cause tissue damage, while performing a sterile dressing change for Resident #1. 2. The facility failed to ensure Resident #1 and Resident #2 had their central lines maintained per professional standards, physician's order, or facility policy. These failures could place the residents with central lines at risk for serious infection, impaired nutrition, and hospitalization. Findings included: 1) Review of Resident #1's undated face sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypomagnesemia (low magnesium level in the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-12 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    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 revies, the facility failed to have sufficient nursing staff with appropriate competencies and skills sets to provide nursing services to assure resident safety and maintain the highest practicable, physical, well-being of the resident for two (Resident #1 and Resident #2) of two residents and three (RN A, RN C, and LVN D) of four staff reviewed for competent nursing. 1. The facility failed to ensure RN A and LVN B stopped administration of TPN (nutrition administered intravenously through a large vein near the heart) which could cause tissue damage while performing a sterile dressing change for Resident #1. 2. The facility failed to ensure nursing staff (RN A, RN C, and LVN D) who cared for residents with central lines (Resident #1 and Resident #2) were competent in providing care following physician orders and facility policy. These failures could place the residents with central lines at risk for serious infection, impaired nutrition, and hospitalization. Findings…

    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 before2023-09-26 · 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 interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to meet his or her preferences, goals, and address his or her medical, physical, mental, and psychosocial needs for 2 of 7 residents (Residents #1 and #2) reviewed for care plans in that: 1. Resident #1 did not have a comprehensive person-centered care plan that addressed her falls on 09/09/2023, 09/13/2023, and 09/24/2023. 2. Resident #2 had a comprehensive person-centered care plan that was started on 08/22/2023 with no completion date. These failures could place residents are risk of not having their preferences, goals, and needs met. Findings included: Review of Resident #1's face sheet, dated 09/26/2023, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including unspecified cerebral infarction (stroke), dysarthria (difficulty speaking because the muscles for speech are weak), essential (primary) hypertension (high blood…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-09-26 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    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 reviews, the facility failed to ensure that each resident received treatment and care in accordance with professional standards of practice for 1 of 7 residents (Resident #1) reviewed for quality of care in that: Staff did not monitor, assess, and document neurological checks on Resident #1 after her falls on 09/09/2023, 09/13/2023, and 09/24/2023. This failure could place residents at risk of pain, mental anguish, emotional distress, physical harm, diminished quality of life, and death. Findings included: Review of Resident #1's face sheet, dated 09/26/2023, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including unspecified cerebral infarction (stroke), dysarthria (difficulty speaking because the muscles for speech are weak), essential (primary) hypertension (high blood pressure), obstructive sleep apnea, and age-related physical debility. Review of Resident #1's five-day MDS assessment, dated 09/13/2023, reflected a BIMS score of 7,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-09-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    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 observation, interviews and record reviews, the facility failed to ensure the resident environment remained free of accidents and hazards and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 7 residents (Resident #1) reviewed for accidents and hazards in that: The facility failed to supervise Resident #1, who fell once on 09/09/2023, twice on 09/13/2023, and once on 09/24/2023. This failure could place residents at risk for further falls, pain, and/or injury. Findings included: Review of Resident #1's face sheet, dated 09/26/2023, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including unspecified cerebral infarction (stroke), dysarthria (difficulty speaking because the muscles for speech are weak), essential (primary) hypertension (high blood pressure), obstructive sleep apnea, and age-related physical debility. Review of Resident #1's five-day MDS assessment, dated 09/13/2023, reflected a BIMS score of 7,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2025-03-20 · tag F0851 — widespread
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information for the third quarter (April 1, 2024, to June 30, 2024) reviewed for Administration. The facility failed to submit complete PBJ staffing information to CMS for April 1, 2024, to April 30, 2024. This failure could place all residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Findings Included: Record review of the Casper3 PBJ report revealed the facility had four areas triggered on the FY Quarter 3 (April1- June30) report. The areas were One Star Staffing Rating, Excessively low Weekend Staffing, No Rn hours, and Failed to have Licensed Nursing Coverage 24 hours/day. The report details no RN hours for every day in April 2024. It also details Failed to have Licensed Nursing Coverage 24 hours/day for every day in April 2024. Record review of an email sent from the Administrator on 03/18/25 at 11:37 AM…

    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.

    Administration 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

$12,356 in federal fines across 1 penalty.

  • $12,356 — penalty dated 2024-06-23

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 TOUCHSTONE COMMUNITIES — 25 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 52.9+1.1 vs chain
Health inspection 4 of 53.0+1.0 vs chain
Staffing 2 of 51.7+0.3 vs chain
Quality measures 4 of 54.0≈ chain avg
The other 24 homes this chain runs (chain average 2.9★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleSince
APOLINAR, ADAMIndividualCORPORATE OFFICERsince 08/01/2015
CONTRERAS, TERRIIndividualCORPORATE OFFICERsince 04/29/2019
TOUCHSTONE STRATEGIES - COPPERAS COVE, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/12/2025
TOMPKINS, JEFFERYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/17/2025
OOMMEN, BIJUIndividualADP OF THE SNFsince 07/26/2010

CMS files one row per role, so the 7 rows in the source record cover these 5 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.

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.

$7.2M
Net patient revenuemost recent cost report
-12.4%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 48%Medicare 9%Other / private 43%

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

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$348per resident / day
operating cost
$10,567per month
≈ monthly operating cost
$309per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in TX

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 675536. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-21, 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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