Brookdale Trinity Towers
317 N Carancahua, Corpus Christi, TX 78401 · For profit - Limited Liability company · 75 certified beds · (361) 887-2000 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- a high payroll-based staffing rating (5/5)
- 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 $16,449 in federal fines (most recent 2023-12-02)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 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 | 17.5% | 15.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 7.0% | 3.0% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.4% | 0.3% | 0.9% | worse 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 | 3.8% | 2.4% | 6.5% | worse 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 | 6.9% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 22.7% | 14.0% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 34.1% | 18.0% | 18.9% | worse |
| Long-stay residents with pressure ulcers | 2.1% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 23.4% | 13.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 3.6% | 9.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.3% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 99.7% | 88.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 21.0% | 25.7% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 9.1% | 12.3% | 12.0% | better |
‡ 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.
62.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 208 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 51.0% 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 100 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 0.76 therapist hours per resident per day in 2026Q1 — more than 94% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 27% 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 | 62.8%CMS range 55.1–67.6 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.3%CMS range 9.0–16.1 | 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 | 51.0% | 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 | 50.0% | 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 | 47.0% | 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 | 91.5% | 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 | 100.0% | 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 | 98.9% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.2%CMS range 4.0–11.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.92 | 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 75 beds and averages 48.4 residents a day — about 65% occupied, or roughly 27 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.42 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.12 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.84 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 4.01 hrs/resident/day on weekends vs 4.59 on weekdays — 13% thinner on weekends. RN hours go from 1.23 to 0.83 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 47% 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.
- Immediate jeopardy · J2023-12-02 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for one of one resident (Resident #198) reviewed for tracheostomy care . 1. The facility failed to ensure Resident #198 had suction equipment, emergency supplies, a spare trach or a care plan specific for tracheostomy care. 2. The facility failed to ensure staff could describe steps to take in the event of an emergency dislodgement of Resident #198's trach. 3. The facility failed to ensure staff were competent in trach care and knowledgeable of equipment needed. These failures could place residents at risk for suffocation and death. The facility Administrator and DON were notified on 11/29/23 at 5:32 PM, that an Immediate Jeopardy situation had been identified due to the above failures. While…
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 F0627 — isolatedEnsure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
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 reviews and interviews, the facility failed to ensure that one resident (Resident #2) of five residents discharged did not receive the required 30-day notice of discharge. The facility failed to ensure Resident #2 was given a 30-day discharge notice. Resident #2 was discharge on [DATE]. The failure could put residents at risk for inappropriate discharge from the facility and cause psychological harm due to feelings of anger and sadness. This failure could place discharged residents at risk of being discharged from the facility causing a disruption in their care and/or services The findings included: Review of Resident #2's face sheet dated 06/04/26 revealed she was a [AGE] year-old female admitted on [DATE] with diagnosis that included chronic obstructive pulmonary disease (a progressive, incurable lung disease that restricts airflow and making breathing difficult), Acute Respiratory Failure (respiratory system suddenly fails to oxygenate the blood), Syncope (fainting or passing out). 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.
- Potential for harm · D2026-06-04 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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 reviews and interviews, the facility failed to send a copy of the discharge notice, prior to the discharge, to the representative of the Office of State Long-Term Care Ombudsman for two residents (Resident #1 and Resident #2) of five residents reviewed for discharge. The facility failed to send a copy of Resident #1 and Resident #2's discharge notice, prior to discharge, to the representative of the Office of State Long-Term Care Ombudsman. These failures could have placed the residents at risk of not knowing their rights or receiving the services of the state Long Term-Care Ombudsman. Findings Included: Review of Resident #1 face sheet dated 06/04/26 revealed she was an [AGE] year-old female admitted on [DATE] with diagnosis of dysphagia (difficulty swallowing); hypertension (a chronic condition in which the force of blood against your artery wall is consistently too high); osteoporosis (a bone disease that causes bones to become weak, brittle, and highly susceptible to fractures). In an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-05-21 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 6 residents (Resident #1) reviewed for medical records.The facility failed to document the amount of food Resident #1 ate during her 3 meals per day for 10 times from March 1st through March 15th, 2026. This failure could place residents at risk of not receiving proper care or having needs met due to inappropriate documentation.The findings included:Record review of Resident #1's face sheet, dated 05/19/26, revealed a [AGE] year-old female, admitted [DATE] and discharged [DATE]. The pertinent diagnosis included Type 1 Diabetes (chronic autoimmune disease where the body's immune system attacks insulin-producing cells in the pancreas). Record review of Resident #1's admission MDS Assessment, dated 05/06/26, revealed a BIMS score of 13 indicating her cognition was intact. 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 · Dcited before2026-04-30 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
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 complete a comprehensive assessment within 14 calendar days after admission as required for 1 (Resident#70) of 7 resident records reviewed for assessment. The facility failed to complete Resident #70's comprehensive MDS assessment within 14 days following her admission to the facility on [DATE]. This failure could place newly admitted residents at risk of not receiving the proper care required to attain or maintain the highest practicable physical, mental, and psychosocial well-being.The findings included:Record review of Resident #70's admission Record reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Her pertinent diagnoses included fracture of the superior rim of the left pubis (a break in one or more of the bones that make up the pelvis), muscle weakness (a sensation of imbalance or difficulty maintaining steady posture while standing or walking), and lack of coordination (difficulty in controlling and executing smooth,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-30 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 for each resident, consistent with resident needs, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 of 7 residents (Resident #60) reviewed for care plans. The facility failed to ensure Resident #60's care plan reflected her ADLs with assistance needed.This failure could place the residents at risk of not receiving appropriate interventions and care to meet their needs.Findings included:Record review of Resident #60's face sheet, dated 04/28/26, reflected a [AGE] year-old female, admitted on [DATE], diagnoses included: congestive heart failure (long-term condition that affects the heart's ability to pump blood), major depressive disorder (mental health condition with persistent feelings of sadness, loss of interest, various emotional/physical problems), chronic kidney disease (condition that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-30 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 review and revise the comprehensive care plan by the interdisciplinary team, for 1 of 7 residents (Resident #7) reviewed for comprehensive care plan revisions. The facility failed to review and revise Resident #7's care plan to reflect she no longer used a catheter.This failure could place the residents at risk of not receiving appropriate interventions and care to meet their current needs.Findings included:Record review of Resident #7's face sheet, dated 04/29/26, reflected a [AGE] year-old female, admitted on [DATE], diagnoses included: unspecified dementia (decline in cognitive function severe enough to interfere with daily life affecting memory loss, language, problem solving, and other cognitive abilities), acute kidney failure (condition that affects the kidneys' ability to filter waste from the blood), hypertensive heart disease (condition caused by prolonged high blood pressure leading to heart damage) , anxiety disorder…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-30 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to ensure a resident receives treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, and maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or the resident preferences indicate otherwise for 1 (Resident #70) of 7 residents reviewed for nutritional status.The facility failed to ensure Resident #70 was weighed weekly for 3 weeks after admission per physician's orders. This failure could place residents at risk for nutritional deficit, weight loss, skin breakdown, and overall decline in quality of life.The findings included:Record review of Resident #70's admission Record reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Her pertinent diagnoses included fracture 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 · D2026-04-30 · 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 observation and interview, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident in 2 of 2 medication rooms (4th floor and 5th floor) reviewed for pharmacy services.The facility failed the ensure expired medication was removed from the 4th floor medication storage room.The facility failed the ensure expired medication was removed from the 5th floor medication storage room.These failures could place residents at risk of not receiving the therapeutic benefit of medications and or adverse reactions to medications.The findings included:An observation of the 4th floor medication room on 04/30/26 at 11:00 am reflected 2 unopened 16 oz bottles of Geri-Tussin (an expectorant- a medication used to thin and loosen mucus) with an expiration date of 2025/07 in a cabinet where backstock OTC (over the counter) medications were stored.An observation of the 5th floor medication room on 04/30/26 at 11:30 am reflected 1 unopened…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-30 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to store food in accordance with professional standards for 1 of 1 freezer and 1 of 2 medication storage rooms (4th floor medication room) reviewed for food safety.-The facility failed to ensure food items (raw dinner rolls, breaded chicken tenders, and breaded fish) in the freezer were sealed properly.-The facility failed to ensure resident food items were disposed of according to policy. -The facility failed to ensure the resident food and drink refrigerator in a medication storage room was clean and did not have any food or drink remnants in it. These failures could place residents at risk of complications from food contamination.Findings included:Observations during the initial tour of the kitchen on 04/28/26 at 8:25 AM revealed the freezer had boxes of raw dinner rolls, breaded chicken tenders, and breaded fish that were open and exposed to the air.During an interview, on 04/30/26 at 10:55 AM, DA B stated all kitchen staff 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.
- Potential for harm · Dcited before2026-04-30 · 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
Based on observation and interviews, 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.The facility failed to ensure infusion therapy supplies were stored under sterile conditions in the 4th floor medication storage room.The facility failed to ensure used oxygen equipment was not stored in the 4th floor medication storage room.These failures could place residents at risk of cross contamination and infection.The findings included:An observation of the 4th floor medication room on 04/30/26 at 11:00 am reflected unused IV infusion tubing that had been removed from the packaging laying in the bottom of a drawer that contained various other properly packaged and sterile supplies. This observation also reflected a 340 ml bottle of sterile water used for oxygen humification in the back left corner of the top shelf in the bottom storage cabinet. This bottle was not full and was not in a package.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 12 citations
- Potential for harm · Dcited before2025-09-10 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 interview and record review, the facility failed to ensure the comprehensive care plan was developed and implemented within a timely manner for each resident consistent with resident rights to include measurable objectives and timeframes to meet residents medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for 1 (Resident #1) out of 5 residents reviewed for care plans. The facility failed to add the fall with significant injury, fall mats, and the surgical wound with wound care to Resident #1's care plan. The facility also failed to complete Resident #1's comprehensive care plan within the specified time frame.These failures could place residents at risk for receiving inadequate care and services. Findings included:Record review of Resident #1's face sheet dated 09/10/2025 revealed a [AGE] year-old female with an initial admission date of 08/18/2025 and a current admission date of 09/09/2025. Pertinent diagnoses included Displaced Oblique Fracture of Shaft 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 · Fcited before2025-02-20 · 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, 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 (K2) reviewed and 2 of 2 satellite kitchens (SK4 and SK2) for storage, preparation, and sanitation. 1. Satellite Kitchen 4 (SK4) The facility failed to maintain cleanliness of the steam table holding wells and shelf, that a cleaning schedule was followed, personal items were not kept in the dry storage room, and all staff wore a hair and beard net while in SK4. 2.Satellite Kitchen 2 (SK2) The facility failed to maintain cleanliness of the steam table holding wells and shelf, that a cleaning schedule was followed, and personal items were not kept in the server room, in SK2. 3. Main Kitchen 2 (K2) The facility failed to maintain cleanliness of the steam table holding wells and shelf, the convection oven, the trash cans, a floor blower, and that a cleaning schedule was followed in K2. The facility failed to ensure spices were kept closed throughout the survey to prevent cross…
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 before2025-02-20 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 3 of 12 residents (Residents #15, #33, and #152) observed for infection control practices. The facility failed to post Enhanced Barrier Precaution signs outside the rooms of Resident #'s 15, 33 and 152. These failures could place residents, staff, and visitors at risk of cross contamination and/or infection. Findings included: 1. Record review of Resident #15's face sheet dated 02/20/25 revealed a [AGE] year-old-male with an original admission date of 04/08/24 and a current admission date of 02/03/2025. Diagnoses included Squamous Cell Carcinoma of Skin, Scalp, and Neck (a type of skin cancer that was caused by an uncontrolled growth of abnormal squamous cells). Record review of Resident #15's admission MDS assessment dated [DATE], section C,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-02-20 · tag F0908 — failed to keep essential equipment working — patternKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to maintain all kitchen equipment in safe operating condition for 1 of 1 kitchen (K2) reviewed and 1 of 2 satellite kitchens (SK2) reviewed for safe operating equipment. The facility failed to maintain a chest type freezer with heavy ice build-up on the inside walls, bottom, and lid in SK2. The facility failed to maintain and remove a 4-foot X 3-foot char broiler that did not work, had no griddle on it, and was connected to the gas line in K2. The facility failed to maintain and remove dented holding pans and dented prep equipment (food mill) in K2. The facility failed to maintain the walk-in freezer by not allowing ice accumulation around the fan and low lighting in K2. These failures could cause food-borne illness from equipment not being maintained and/or cleaned effectively. Findings include: Observation and initial tour of SK2 (satellite kitchen 2nd floor) on 02/18/25 at 11:35 am revealed a chest type freezer had heavy ice build-up on the inside walls, bottom, and lid and a removable black substance on 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 before2025-02-20 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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, observations and record review, the facility failed to develop a comprehensive person-centered care plan based on assessed needs that included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #15 and Resident #30) of 16 residents reviewed for comprehensive person-centered care plans. The facility failed to develop and implement Resident #15's care plan to include oxygen therapy. The facility failed to develop and implement Resident #30's care plan to include oxygen therapy. This failure could affect the resident by placing them at risk for not receiving care and services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The findings included: 1. Record review of Resident #15's face sheet dated 02/20/25 revealed…
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 · E2023-12-02 · tag F0688 — failed to keep residents mobile / prevent decline — patternProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for two residents (R #159 and R #200) reviewed for restorative care. The facility failed to apply knee immobilizer to Resident #159's knee to reduce the risk of further loss of range of motion. The facility failed to back immobilizer to Resident #200's back to reduce the risk of further loss of range of motion. This failure placed residents on restorative nursing care at risk for decline in range of motion, and decreased mobility. The findings: Record review of R 159's #'s Face Sheet dated 11/28/2023, documented a [AGE] year-old female admitted [DATE], with the diagnoses of, fracture of the left patella (knee fracture), heart failure, Diabetes type 2 (insufficient production of insulin in the body), and malignant neoplasm of the breast (breast cancer). Record review of R…
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 · E2023-12-02 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for of two of five medication carts (200 and 300 Hall 2nd floor Medication Cart) reviewed for medication storage The facility failed to ensure, 200 and 300 hall medication carts were locked when unattended. This deficient practice could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed mediations. Findings include: Observation on 11/28/2023 at 1:08 pm revealed two medication carts unlocked. The Charge nurse was observed to be behind the nurses' station. The State Surveyor walked towards the medication carts and was able to open drawers and pull out a variety of medications. Interview on 11/28/2023 at 1:23 pm revealed LVN A took ownership of the unlocked medication cart and went to the nurses' station to work on other tasks she had 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 · Ecited before2023-12-02 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food plates. 1. Upon two separate visits to the 4th floor satellite kitchen revealed a worn, distressed looking temperature log binder being placed to lean against the food plates that are served to the residents for their meals every day. This failure could place residents at risk for cross-contamination and food-borne illnesses. 2. The facility failed to ensure staff did not store their personal drinks in the preparation area of the facility kitchen. Findings were: 1. In an observation on 11/28/23 at 10:18 a.m. revealed a refrigerator temperature log binder leaning on top of plates that are used to serve the residents on the 4th floor. In an observation on 11/30/23 at 10:38 a.m. the temperature log binder remained leaning against the plates that are utilized to serve the residents on the 4th floor. In an interview on 11/30/23 at 10:42 a.m. with the Dietary Manager revealed that the binder should not be leaning on the plates and it should be placed…
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 before2023-12-02 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
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 conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for one of 30 residents (Resident #200) reviewed for comprehensive assessments. The facility failed to complete an accurate updated comprehensive assessment for Resident #200. This failure could place residents at risk of not having their care and treatment needs assessed to ensure necessary care and services were provided. The findings include: Record review of Resident #200's face sheet, dated 11/28/23, documented an 63- year-old male who was admitted to the facility on [DATE]. Resident #200 had diagnoses which included: spinal stenosis (pressure on the spinal cord and the nerves within the spine), lumbar region without neurogenic claudication (compression of the spinal nerves in the lumbar (lower) spine, encounter for surgical aftercare following surgery on the nervous system. 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 · Dcited before2023-12-02 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 for each resident, consistent with the resident rights, that included measurable objectives, and timeframes to meet a residents medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for two of two residents (Resident #198 and Resident #200) reviewed for care plans. 1. The facility failed to develop a care plan to address Resident #198's tracheotomy care needs or address emergency management in the event of a dislodgement. 2. The facility failed to correctly assess/identify/document Resident #200's current physical functioning and the use of a back brace in his initial assessment dated [DATE]. These failures could place resident's at risks of suffocation or death. The findings included: 1. Record review of Resident #198's face sheet, dated 11/29/2023, reflected 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 before2023-12-02 · 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, and interview, 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 Resident #160 of 55 residents reviewed for infection control. 1. LVN C did not perform hand hygiene for 20 seconds or greater while performing wound care on Resident #160. These failures could place residents at risk for infection through cross contamination of pathogens. The findings include: 1.) Record review of Resident #160's face sheet, dated 12/1/2023, documented a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #160 had diagnoses which included atrial fibrillation (hearts upper chambers beat out of coordination with the lower chambers), displacement of cardiac pulse generator (battery) subsequent encounter for surgical aftercare following surgery on the circulatory…
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 before2023-09-23 · 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, record review, and interview, 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 one resident (Resident -R# 1) of five residents that were reviewed for infection control and transmission-based precautions policies and practices, in that: The facility failed to ensure LVN A performed hand hygiene and removed her contaminated gloves prior to the commencement of perineal care after she touched multiple surfaces. This failure could place residents at risk for infection through cross contamination of pathogens. The findings included: Record review of R #1's Face Sheet dated 09/23/2023, admitted on [DATE] revealed a [AGE] year-old female with the following diagnoses of: acute kidney failure, Parkinson's disease, epilepsy, congestive heart failure, and morbid (severe)obesity. Record review of R…
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
$16,449 in federal fines across 1 penalty.
- $16,449 — penalty dated 2023-12-02
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 BROOKDALE SENIOR LIVING — 12 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 | 5 of 5 | 3.5 | +1.5 vs chain |
| Health inspection | 4 of 5 | 2.8 | +1.2 vs chain |
| Staffing | 5 of 5 | 4.1 | +0.9 vs chain |
| Quality measures | 4 of 5 | 4.3 | -0.3 vs chain |
The other 11 homes this chain runs (chain average 3.5★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| AMERICAN RETIREMENT CORPORATION | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 02/12/1997 |
| BROOKDALE SENIOR LIVING INC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 06/28/2005 |
| KUSSOW, DAWN | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | since 04/30/2025 |
| WHITE, CHADWICK | Individual | INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 03/09/2018 |
| CAPITAL ONE NA | Organization | 5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST | since 10/13/2022 |
| BOWMAN, KEVIN | Individual | MANAGING CONTROL - GOVERNING BODY | since 10/01/2021 |
| DEEN, LORI | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 07/22/2025 |
| GALBREATH, SHEILA | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 07/22/2025 |
| HOLLOWELL, KATHY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/22/2025 |
| LA MARRE, KEVIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 01/22/2017 |
| MUNOZ, ANNA | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 02/15/2024 |
| PENNINGTON, BRENT | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/22/2025 |
| RUIZ-CERROS, MARISSA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/02/2020 |
| STENGLE, NIKOLAS | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 11/08/2025 |
| TERRELL, DAMIRA | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 07/22/2025 |
| ARC CORPUS CHRISTI, LLC | Organization | GENERAL PARTNERSHIP INTEREST | since 01/02/1990 |
| ARC LP HOLDINGS, LLC | Organization | LIMITED PARTNERSHIP INTEREST; ADP OF THE SNF | since 09/24/2002 |
| ASHER, JORDAN | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 10/07/2025 |
| DRAYTON, CLAUDIA | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 10/07/2025 |
| FIORAVANTI, MARK | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 10/07/2025 |
| FREED, VICTORIA | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 10/07/2025 |
| HAUSMAN, JOSHUA | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 10/07/2025 |
| MACE, ELIZABETH | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 10/07/2025 |
| WARREN, DENISE | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 10/07/2025 |
| WIELANSKY, LEE | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 10/07/2025 |
| BKD SHORELINE LLC | Organization | ADP OF THE SNF | since 02/12/2015 |
| LBMC PC | Organization | ADP OF THE SNF | since 01/01/2024 |
| TRINITY TOWERS LIMITED PARTNERSHIP | Organization | ADP OF THE SNF | since 02/12/2015 |
| WALTERS FINANCIAL SERVICES INC | Organization | ADP OF THE SNF | since 07/22/2025 |
CMS files one row per role, so the 40 rows in the source record cover these 29 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.
9 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.
This home reported $1.2M paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in TX
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 675773. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-30, 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 →
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