Avir At Corpus Christi
202 Fortune Dr., Corpus Christi, TX 78405 · For profit - Limited Liability company · 121 certified beds · (361) 252-0734 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- 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 (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $14,069 in federal fines (most recent 2025-03-26)
- its facility-reported quality-measure score sits well above its independent inspection score
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 7.1% | 15.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.8% | 3.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.4% | 2.4% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.9% | 3.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 7.7% | 14.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 6.9% | 18.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 95.2% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.4% | 3.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 16.4% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 5.0% | 9.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.9% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 57.9% | 88.0% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 17.1% | 25.7% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 4.1% | 12.3% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.66 | 2.17 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.43 | 2.06 | 1.80 | worse |
‡ 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.
58.6% 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 27 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 85.3% 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 34 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 0.35 therapist hours per resident per day in 2026Q1 — more than 59% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 58.6%CMS range 45.4–70.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.8%CMS range 6.8–15.3 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 85.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 70.6% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 76.5% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 97.9% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 96.2% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.5%CMS range 4.2–13.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.71 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 121 beds and averages 91.3 residents a day — about 75% occupied, or roughly 30 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 3.01 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.23 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.89 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 2.67 hrs/resident/day on weekends vs 3.15 on weekdays — 15% thinner on weekends. RN hours go from 0.27 to 0.13 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 36% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
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.
29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.
- Immediate jeopardy · J2025-03-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one (Resident #1) of 5 residents reviewed for supervision. The facility failed to ensure Resident #1 received adequate supervision while Resident #1 was unaccounted for approximately 10 minutes from 9:05 PM to 9:15 PM on 12/13/24 before LVN C found Resident #1 alone in the 100-hall shower room on the floor. Resident #1 sustained an injury to his head from the fall and was taken to a local hospital where he was diagnosed with an acute on chronic intracranial subdural hematoma (occurs when a new, acute bleed happens to a pre-existing chronic subdural hematoma, often triggered by even minor trauma. A subdural hematoma is a collection of blood that accumulates between the brain and the innermost layer of the skull). The noncompliance was identified as PNC. The PNC began on 12/13/24 and ended on 12/14/24. The facility had corrected the noncompliance before the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2026-06-04 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
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 a registered nurse served as the full time Director of Nursing for 1 of 1 facility reviewed for nursing services. The facility failed to designate a registered nurse to serve as the full time DON since 04/25/2026. This failure could place residents at risk of receiving inadequate care, as well as cause a lack of nursing oversight and higher level of care. The findings included: Record review of the DON timecard coverage report from 04/25/2026 through 06/04/2026 indicated there was no DON in facility. The timecard revealed the RNC had been in the facility three days per week (24 hours per week) since the previous DON's last day on 04/24/2026. Record review of the Clinical Staffing Schedules for May of 2026 revealed the DON spot was blank.In an observation on 06/03/2026 throughout the day, the RNC was not observed in the facility.In an observation on 06/04/2026, throughout the day, the RNC was observed rounding in the facility and speaking with the nursing staff throughout the day. In an interview 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.
- Potential for harm · Dcited before2026-06-04 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the appropriate State Agency, but no later than 2 hours after the allegation was made, for 1 of 5 Residents (Resident #2) reviewed for freedom from abuse and/or neglect.The facility failed to report Resident #2's allegation of verbal abuse by a staff member on 05/17/2026. The state agency was notified on 05/19/2026.This failure could result in placing residents at increased risk for further abuse, as well as not receiving a proper or thorough investigation.The findings included:Record review of Resident #2's face sheet, dated 06/04/2026, revealed a [AGE] year-old male with an admission date of 01/09/2026. Pertinent diagnoses included Type 2 Diabetes (a chronic condition which affects how your body metabolizes sugar [glucose], leading to high blood sugar levels and various health complications), and Morbid (severe) Obesity. Record 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.
- Potential for harm · D2026-06-04 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were labeled and stored appropriately for 1 of 4 medication carts (300 Hall Medication Cart) and 1 of 1 Emergency Crash Cart reviewed for pharmacy services. 1. The facility failed to ensure the 300 Hall Nurse Med-Cart was locked and secured.2. The facility failed to ensure the Emergency Crash Cart was locked and secured. These failures could place residents at risk of taking or ingesting medications and/or medical supplies which could have caused them harm.The findings included:An observation on 06/03/2026 at 11:49 AM of the 300 Hall Medication Cart, parked at the nurses' station, revealed an unlocked cart which was able to be accessed. The lock was popped out, and all drawers were able to be accessed except the narcotic drawer. There were staff behind the nurses' station on the computers, and residents in wheelchairs around the nurses' station. An observation on 06/03/2026 at 11:57 AM of the Emergency Crash Cart, parked in a cubby on the 200 hall, revealed it was unlocked and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-04 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to 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 5 residents (Residents #1) reviewed for infection control practices.1. The facility failed to ensure the IP, the WCN, and LVN-B knew the proper placement of the PPE cart for Resident #1.2. The facility failed to ensure the physician's order for EBP was obtained prior to placing Resident #1 on precautions. These failures could place residents at risk of cross contamination and/or infection.The findings included: Record review of Resident #1's face sheet, dated 06/03/2026, revealed a [AGE] year-old-male with an original admission date of 06/22/2025 and a current admission date of 03/19/2026. Pertinent diagnoses included Type 2 Diabetes Mellitus (a chronic disorder characterized by high blood sugar levels due…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-09-04 · tag F0760 — failed to prevent significant medication errors — patternEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 2 of 5 residents (Residents #42 and #89) reviewed for pharmacy services. 1. The facility failed to clarify the blood pressure parameters for Resident #42's Midodrine (a medication used to treat hypotension, or low blood pressure) orders started [DATE]. 2. The facility failed to administer Resident #42's and Resident #89's Midodrine per the recommended and prescribed order and blood pressure parameters in August of 2025. These failures could place residents at risk for complications and jeopardize their health and safety. 1. Record review of Resident #42's face sheet, dated [DATE], revealed a [AGE] year-old male with an admission date of [DATE]. Pertinent diagnoses included hypotension (low blood pressure). Record review of Resident #42's admission MDS assessment, dated [DATE], revealed a BIMS score of 15, which revealed intact cognition. The MDS also revealed an active diagnosis of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-09-04 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed and 1 of 1 nutrition room for storage, preparation, and sanitation. 1. The facility failed to ensure there were no personal items in the walk-in refrigerator or on the tray line. 2. The facility failed to ensure all items in the walk-in refrigerator were labeled and dated. 3. The facility failed to ensure there was an internal thermometer in the walk-in refrigerator. 4. The facility failed to ensure there was no ice accumulation in the walk-in freezer. 5. The facility failed to ensure that boxes of food in the walk-in freezer were sealed tightly and at least 18 inches from the ceiling. 6. The facility failed to ensure that juice guns were clean and not hanging over the edge of the prep table. 7. The facility failed to ensure all employees entering the kitchen had hairnets on. 8. The facility failed to ensure all electric stove top burners worked. 9. The facility failed to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-04 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures for 1 of 6 Residents (Resident #48) reviewed for reporting. In an interview with the ADM on 09/03/25 at 5:33 pm, he said he was informed about the incident with Resident #48 by the DON on or about 08/16/25, and since the DON was taking care of it, he had not remembered it when he and this state surveyor spoke on 09/03/25 at 5:06 pm. He said name-calling was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-04 · tag F0655 — isolatedCreate 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 interview and record review, the facility failed to ensure a baseline care plan which included the instructions for resident care needed to provide effective and person-centered care was implemented within 48 hours of admission for 1 (Resident #100) of 5 residents reviewed for baseline care plans. The facility did not develop a baseline care plan within 48 hours of admission for Resident #100. This failure could place residents at risk of not receiving person-centered care and/or services to meet their physical and/or psychosocial needs.Findings included: Record review of Resident #100's face sheet, dated 09/02/2025, revealed she was a [AGE] year-old female originally admitted on [DATE], readmitted on [DATE], and discharged on 09/02/2025. Pertinent diagnoses included Chronic Obstructive Pulmonary Disease (a lung condition caused by damage to the airways and alveoli, usually from smoking or other irritants), Dyspnea (shortness of breath), and Dependence on Supplemental Oxygen (Oxygen therapy to help…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-04 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services 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 interview and record review, the facility failed to ensure dialysis services were provided consistent with professional standards of practice for 1 of 1 resident (Resident #6) reviewed for quality of care. The facility failed to ensure Resident #6 had a physician's order to assess the dialysis shunt or fistula (a dialysis access which allows the removal of waste and extra fluid). The facility failed to monitor Resident #6's dialysis catheter by assessing for the thrill and bruit each shift. These failures could place residents at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: Record review of Resident #6's face sheet, dated 09/04/2025, revealed a [AGE] year-old male with an admission date on 03/09/2022 and readmission on [DATE]. Pertinent diagnoses included End Stage Renal Disease (when the kidneys no longer adequately filter waste products from the blood), Diabetes Mellitus Type 2 (a group of diseases which affect how the body uses blood…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-04 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 resident (Resident #89) of 6 residents reviewed for infection control practices.1) The facility failed to ensure the WCN performed hand hygiene after removing gloves prior to performing wound care on Resident #89 and after sanitizing scissors.This failure could place residents at risk for healthcare associated cross-contamination and infections.Findings include:Record review of Resident #89's face sheet, dated 09/04/25, reflected a [AGE] year-old-male with an initial admission date of 06/01/23. Diagnoses included stage 4 (full thickness tissue loss, exposing underlying structures such as muscle, tendon, or bone) pressure ulcer of the sacral (tailbone) region and right ankle, type two diabetes (insufficient insulin…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 18 citations
- Potential for harm · Dcited before2025-07-15 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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 record review and interview, the facility failed to maintain clinical records in accordance with accepted professional standards of practice, that were complete and accurately documented, for one resident (Resident #1) of three residents reviewed for personal inventory log. When Resident #1 was admitted on [DATE], LVN A failed to complete an accurate inventory log for Resident #1's belongings. This failure could jeopardize a resident from having their valuables properly recorded, which in turn could result in a resident's valuables being misplaced and/or not returning home with the correct resident. The findings included: Record review of Resident #1's admission record dated 07/15/2025, revealed Resident #1 was a [AGE] year-old female who was initially admitted on [DATE] and readmitted on [DATE] and later discharged [DATE] to home with hospice. Resident #1's primary stay was for Respite Hospice. Resident #1 had diagnoses of acute diastolic (congestive) heart failure, and type 2 diabetes (sugar…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-03-26 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, documenting, and administering of all drugs and biologicals) to meet the needs of each resident for 3 of 5 residents (Residents #4, #2, and #3) reviewed for pharmacy services. The facility failed to ensure LVN-A signed her MAR when she administered PRN narcotics to Residents #4, #2 and #3. The facility failed to ensure LVN-A wasted her PRN narcotic medications with another licensed nurse. These failures could place residents at risk for not receiving, or receiving more than intended amount of, PRN narcotic medications. Findings included: Record review of Resident #4's face sheet dated 03/26/25 revealed a [AGE] year-old female with an admission date of 08/25/2024, and a discharge date of 09/06/24. One of her diagnoses included Systemic Inflammatory Response Syndrome (an exaggerated defense response of the body to a harmful stressor, such as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-07-31 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for dietary services. 1. The facility failed to ensure that food items in the walk- in cooler were labeled and dated. 2. The facility failed to ensure that food items in the walk- in cooler were discarded after the use by date. 3. The facility failed to ensure that food containers in the walk- in cooler were tightly sealed. 4. The facility failed to ensure that items labeled keep frozen were kept in the freezer. 5. The facility failed to ensure that food items in the dry storage area were labeled and dated. 6. The facility failed to ensure that food items were refrigerated after opening per the manufacturer's label. 7. The facility failed to ensure that food items in the dry storage area were closed and/or sealed properly. 8. The facility failed to ensure that food items in the reach in cooler were labeled and dated. 9. The facility failed to ensure that food items in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-07-31 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably 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, interview and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preference for four (Residents #254, #26, #66, #86) of fourteen residents reviewed for call light. The facility failed to ensure Residents #254, #26, #66, #86's call lights were within reach. This failure could place residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings were: 1.Record Review of Resident #254's face sheet dated 7/31/2024 indicated she was a [AGE] year-old female admitted on [DATE] with the diagnoses of Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease (a chronic lung disease that causes air flow limitation), Encephalopathy (damage or disease that affects the brain), Muscle Weakness, Chronic Kidney Disease Stage 3 (kidneys have mild to moderate damage, and they are less able to filter waste and fluid out of your blood),…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-07-31 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment for 1 of 27 residents (Resident #4) reviewed for homelike environment. The facility failed to fix a broken face plate covering an outlet, restore damaged walls, investigate a dark substance on the ceiling, and fix a sharps container that was attached to the wall at a single point allowing it to rotate freely. These failures place residents at risk of experiencing a diminished quality of life potentially leading to psychosocial harm. The findings included: Record review of Resident #4's face sheet dated 07/29/2024 reflected a [AGE] year-old female with an initial admission date of 10/17/2017 and a current admission date of 05/08/2023. Pertinent diagnoses included Alzheimer's disease, major depressive disorder with psychotic symptoms and schizoaffective disorder (chronic mental illness causing symptoms of both schizophrenia and a mood disorder at the same time).…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-07-31 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 5 of 6 (Resident #12, Resident #7, Resident#254, Resident#396, and Resident #36) residents reviewed for respiratory care. 1. The facility failed to ensure Resident #12 had the required emergency supplies at bedside including a suction machine, supply of suction catheters, sterile gloves and flush solution on 07/30/2024 at 10:08 AM. 2.The facility failed to ensure Resident #7's oxygen tubing was connected to the concentrator and the oxygen was administered at the correct setting of 2 liters per minute on Resident #7's oxygen concentrator was set at 3 liters per minute 7/29/24 at 9:05 AM. 3.The facility failed to ensure Resident #254's had the oxygen sign posted outside his room entrance door on 7/29/24 at 8:40 AM. 4.The facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-07-31 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 interview the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 3 halls (Hall 200) reviewed for environment. 1) The facility failed to keep the soiled linen utility closet containing dirty linens locked when not in use. 2) The facility failed to keep the oxygen storage room containing empty and full oxygen canisters locked when not in use. 3) the facility failed to keep the central supply storage room containing approximately 40 individual shaving razors locked when not in use. These failures could result in injury for residents who come into contact with sharp implements or hazardous materials. The findings included: During an observation on 07/29/2024 at 10:53 AM, the soiled linen utility closet on hall 200 across from resident room [ROOM NUMBER] was noted to be partially ajar. The sign on the door read Authorized Personnel Only. Inside the room was soiled linens and trash. During an observation on 07/29/2024 at 3:03 PM, the oxygen storage…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-07-31 · tag F0925 — failed to control pests — patternMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to maintain an effective pest control program so that the facility was free of pests in one of one kitchen reviewed for pests. 1. There were multiple live flies and gnats in the kitchen. 2. There were multiple live flies in the dining room. These failures could put residents who consumed food from the kitchen and who ate in the dining room at risk for infection and/or food contamination. The findings included: Observation of the facility's kitchen dry storage area on 07/29/24 at 09:10am revealed 2 flies and approimately 10 gnats that were flying around in the area. Observation of the facility's kitchen food preparation and cooking area on 07/29/24 at 09:45am revealed multiple flies were flying around in the kitchen area and had landed on multiple food preparation surfaces. Observation on 07/29/24 at 11:45am of the facility's dining room revealed multiple flies in the dining room. One resident was noted to have a fly swatter on the dining room table that she was sitting at. In an interview on 07/30/24 at 1:43pm,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-31 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to send a copy of the notice of transfer or discharge and the reasons for the transfer or discharge in writing to the Office of the State Long-Term Care Ombudsman for two (Resident #82 and Resident 93) of two residents reviewed for transfer and discharge. The facility failed to send a transfer or discharge notice in writing to the facility's Ombudsman as soon as practicable when Resident #82 was discharged home on 7/25/24. The facility failed to send a transfer or discharge notice in writing to the facility's Ombudsman as soon as practicable when Resident #93 was discharged to another facility on 5/11/24. This failure could affect residents at the facility by placing them at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and the appeal processes. Findings included: 1. Resident #82 Record Review of Resident #82's face sheet dated 7/31/2024 indicated she was a [AGE] year-old female admitted 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.
- Potential for harm · Dcited before2024-07-31 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for one glucometer (Hall 100 Glucometer check log) of three glucometers reviewed for proper calibration. The facility failed to ensure the 100 hall glucometer was calibrated daily for accuracy of reading on 10 separate days in July 2024. This failure could place residents at risk of not receiving accurate blood glucose measurements to assure reliable results and treatment. The findings included: Record review of the 100 hall glucometer log dated July 2024 reflected no entries to indicate calibration was performed on the following days: 07/02/24, 07/03/24, 07/10/24, 07/11/24, 07/12/24, 07/13/24, 07/16/24, 07/25/24, 07/26/24, 07/30/24. Interview with LVN F on 07/31/24 at 9:55 AM revealed she said glucometer calibrations were performed by the night shift nurse every night. LVN F said she had not checked or noticed that the 100 hall glucometer was not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-31 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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 observations, interview, and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 3 residents (Resident #36 ) reviewed for medication administration. Resident #36's Medication Administration Record (MAR) and Treatment Administration Record (TAR) reflected the administration of oxygen was not accurately documented, the order was not reconciliated or recorded and administration of oxygen was completed and not accurately documented. The deficient practice placed resident #36 and 2 additional residents who receive medications from facility staff at risk for less than therapeutic benefits, and/or not receiving ordered medications/treatments due to inaccurate documentation. The findings included: Record Review of Order Summary for Resident #36 dated 07/30/24 reflected the last order review was 04/19/24 and there is no active order for oxygen on resident profile. Record review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-31 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for one Resident (Resident #44) of four residents observed for infection control practices during personal care, in that: 1.) The facility failed to ensure LVN D performed hand hygiene for 20 seconds or greater after wound care for Resident #44. This failure could place residents that require assistance with personal care at risk for healthcare associated cross-contamination and infection. The Findings included: Record review of Resident #44's face sheet dated 7/31/24 reflected a [AGE] year-old-male with an original admission date of 12/18/20. Diagnoses included type two diabetes (insufficient insulin production in the body), chronic obstructive pulmonary disease (chronic inflammatory lung diseases that causes obstructed air…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-30 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for 1 of 3 residents (Resident #2) reviewed for indwelling catheters. The facility failed to prevent Resident #2's urinary catheter tubing from touching the floor. This failure could place residents at risk for urinary tract infections. Findings included: Record review of Resident #2' admission record dated 11/30/23 reflected Resident #2 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #2 was a [AGE] year-old male with diagnosis which included end stage renal disease(kidney no longer work as they should), diabetes (high blood sugar levels), cirrhosis of the liver (permanent damage to the liver), obstructive and reflux uropathy( functional hinderance of normal urine flow),benign prostatic hyperplasia without lower urinary tract symptoms…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-30 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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, interview the facility failed to ensure the environment remained free of accident hazards as posible for 2 of 2 unlocked resident rooms reviewed for accidents and hazards. The facility failed to ensure the two resident rooms [ROOM NUMBERS] were free of cluttered storage of equipment, Hoyer lifts, furniture, boxes, walkers, wheelchairs in a secured manner. This failure could place residents at risk of being in an unsafe environment and at risk for accidents and injury. Findings include: Observation on 11/29/23 at 8:54 am revealed rooms #222 and #220 located at the end of the 200 hall, were filled to the doorway in an unorganized manner, beds, wheelchairs, furniture, desks, walkers, computers, televisions, closed and opened boxes stacked to the ceiling. Both rooms were unlocked and accessible to residents or staff to enter. A wooden pallet approximately eight feet by eight feet was placed against the wall outside in hallway by room [ROOM NUMBER]. Observation revealed 34 residents residing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-09 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that all allegations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials which included to the State Survey Agency, in accordance with State law through established procedures for one (Resident #1) of 18 residents reviewed for abuse/neglect. The facility staff did not report Resident #1's allegation of abuse to the state agency when Resident #1 voiced his concern of being threatened with a gun. This failure could place residents at risk for abuse or neglect. The findings include: Record review of Resident #1's Face Sheet, dated 10/07/2023, documented a [AGE] year-old male who was admitted to the facility on [DATE].…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-14 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that all allegations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported immediately to the administrator of the facility and to the State Survey Agency, for one (R#1) of 18 residents reviewed for abuse/neglect. The facility staff did not report an incident of injury when R#1 was observed bleeding from eyebrow during perineal care. This failure could place residents at risk for neglect. The findings included: Record review of R #1's Face Sheet dated 08/07/2023 documented a [AGE] year-old female resident admitted to the facility on [DATE]. Her diagnoses were: muscle wasting, mobility abnormalities, dysphagia (swallowing difficulty), right knee contracture, and left knee contracture. Record review of R#1's Annual Minimum Data Set, dated [DATE] noted the following: Brief interview of mental status summary score of 99- (resident was unable to complete the interview). MDS coded R#1…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-04-20 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety for 1 of 1 kitchen reviewed. There was expired chocolate milk in the refrigerator There were dirty dishes on the clean rack There were dented and scratched pans This failure could place residents at serious risk for complications from food contamination. Findings were: Observation and initial tour of the kitchen on 04/18/23 at 09:30 AM revealed 8, 1/2 gallons of chocolate milk with expiration dates of 04/17/23 in the refrigerator with 2 other 1/2 gallons of unexpired chocolate milk. There were 4 full trays of dirty dessert cups on the clean rack mixed in with clean dessert cups. There were 4 Teflon-type pans that were badly scratched, flaking, and hanging on the rack of pans. A large colander that was badly dented was also hanging on the rack of pans. There were 8 small; size 4, 3 large; size 1/4-6, and 3 shallows; size 1/3-6 food-holding steam table pans, that were badly dented. Observation of the clean rack 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.
- No harm found · Bcited before2024-02-16 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide a safe, comfortable, and homelike environment for 3 (RM# 304, RM#112 and RM#216) rooms observed for maintenance. The facility failed to maintain resident occupied RM#304, RM# 112 and RM#216: -RM# 304 had unaligned and broken floor tiles. -RM#112 had part of the ceiling texture was falling. -RM#216 had an unsecured door. These failures could place residents in rooms at risk for injury or a declined sense of worth. Findings were: On 2/15/2024 at 11:45 a.m. observation of RM#216 revealed an upside-down door propped up against the closet in the room. The door was unsecure. On 2/15/2024 at 12:01 p.m. observation of room [ROOM NUMBER] revealed popcorn ceiling texture peeling away from the rest of the ceiling. The ceiling area was above the television area across from the resident's bed. On 2/15/2024 at 12:15 p.m. observation of room [ROOM NUMBER] revealed uneven and disarray of tiles upon entrance to room [ROOM NUMBER]. The tiles 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$14,069 in federal fines across 1 penalty.
- $14,069 — penalty dated 2025-03-26
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 AVIR HEALTH GROUP — 116 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.3 | +1.7 vs chain |
| Health inspection | 3 of 5 | 2.4 | +0.6 vs chain |
| Staffing | 2 of 5 | 1.8 | +0.2 vs chain |
| Quality measures | 5 of 5 | 3.6 | +1.4 vs chain |
The other 115 homes this chain runs (chain average 2.3★, per CMS)
Showing 40 of 115; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| STRATFORD HOSPITAL DISTRICT | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 06/01/2024 |
| CHUMLEY, RICHARD | Individual | CORPORATE OFFICER | — | since 06/01/2024 |
| 202 FORTUNE DR OPCO, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 08/01/2025 |
| FREUND, NOCHUM | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 08/01/2025 |
| MOORE, GREGORY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 06/01/2024 |
| TRAVITSKY, AARON | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 08/01/2025 |
| DAGAN, AMITAI | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 11/21/2025 |
| GOLDBERGER, ABRAHAM | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 11/21/2025 |
| GOLDBERGER, FAIGY | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 11/21/2025 |
| 202 FORTUNE DR PROPERTY OWNER, LLC | Organization | ADP OF THE SNF | — | since 08/01/2025 |
| WELLTOWER NNN GROUP, LLC | Organization | ADP OF THE SNF | — | since 08/01/2025 |
| WELLTOWER OP, LLC | Organization | ADP OF THE SNF | — | since 08/01/2025 |
| DE LA GARZA, ERNEST | Individual | ADP OF THE SNF | — | since 07/31/2020 |
5 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.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in TX
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 455697. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-04, 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.