Corpus Christi Nursing And Rehabilitation Center
2735 Airline Rd, Corpus Christi, TX 78414 · Non profit - Corporation · 120 certified beds · (361) 992-0816 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- 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 an abuse, neglect, or exploitation citation (F0600), cited Feb 2025
- inspectors recorded 2 serious findings 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 (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $13,397 in federal fines (most recent 2024-01-08)
- its payroll-based staffing rating is low (1/5)
- nursing-staff turnover (60%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 3 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 | 3 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 2 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 2 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 | 13.7% | 15.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.4% | 3.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.2% | 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 | 1.4% | 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 | 5.2% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 5.2% | 14.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 20.8% | 18.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 79.2% | 98.0% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 3.2% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 20.2% | 13.4% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 4.9% | 9.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 70.9% | 88.0% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 30.3% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 30.7% | 12.3% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.42 | 2.17 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 5.90 | 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.
54.2% 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 45 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 44.8% 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 29 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 0.32 therapist hours per resident per day in 2026Q1 — more than 52% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 18% 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 | 54.2%CMS range 41.9–70.8 | 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 | 11.7%CMS range 8.1–17.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 44.8% | 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 | 51.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 34.5% | 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 | 88.6% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.3% | 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 | 4.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.5%CMS range 4.1–12.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.98 | 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 120 beds and averages 109.9 residents a day — about 92% occupied, or roughly 10 beds typically open. It runs fairly full. 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 3.00 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.29 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.86 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 3.13 on weekdays — 15% thinner on weekends. RN hours go from 0.37 to 0.10 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 60% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
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.
31 citations, most serious first. The 12 most serious are shown; the remaining 19 are one tap away and print in full.
- Immediate jeopardy · K2024-01-08 · 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 observations, interviews and record reviews, the facility failed to ensure residents were free of any significant medication errors for 1 (Resident #3) of11 residents reviewed for pharmacy services, in that:. LVN C failed to accurately reconcile Resident #3's heart medications of: Hydralazine 50mg Q8hr, Metoprolol 50mg Q12hr, Isosorbide dinitrate 20mg daily, or Nifedipine 20mg Q8hr was not acquired and administered from 11/16/2023-11/24/2023 (8days). Resident #3 was admitted to the hospital from dialysis with diagnoses including NSTEMI type 2 (heart attack), Atrial fibrillation. The noncompliance was identified as PNC. The IJ began on 11/16/23 and ended on 11/28/23. The facility had corrected the noncompliance before the survey began. This deficient practice could place residents who receive blood pressure/heart medications at an increased risk for complications such as decreased blood pressure, decrease pulse, an exacerbation of symptoms and disease process, and potential hospitalization. Findings…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · J2024-01-08 · tag F0635 — isolatedProvide doctor's orders for the resident's immediate care at the time the resident was 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 for 1 of 11 residents (Resident #3) was admitted with physician order for their care reviewed for admission orders, in that. LVN C failed to accurately reconcile Resident #3's hospital instructions to resume medications with the physician for her prescribed heart medication of: Hydralazine 50mg Q8hr, Metoprolol 50mg Q12hr, Isosorbide dinitrate 20mg daily, or Nifedipine 20mg Q8hr from 11/16/2023-11/24/2023 (8days). The noncompliance was identified as PNC. The IJ began on 11/16/23 and ended on 11/28/23. The facility had corrected the noncompliance before the survey began. This failure could have jeopardized the well-being of Resident #3 as well as could have led to the demise of Resident #3. Findings include: Record review of Resident #3's face sheet dated 01/05/2024 documented an [AGE] year-old female with a diagnosis of hyperlipidemia (high cholesterol), hypertension (high blood pressure), atherosclerotic heart disease (damage or disease 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 · Dcited before2026-03-30 · 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 #1) of five residents reviewed for meal percentage logs.The facility failed to document the meal percentages in Resident #1's electronic health record on 02/28/2026, 03/17/2026, and 03/23/2026 as per the facility's Medical Record documentation Policy. This failure could jeopardize residents from receiving adequate nutrition and assessment which could compromise the residents' specific dietary needs. Record review of Resident #1's admission record dated 03/28/2026 revealed Resident #1 was initially admitted on [DATE]. Resident #1 was admitted with multiple diagnoses including Alzheimer's disease (cognition disease), dementia (memory deficit), muscle wasting and atrophy (wasting), not elsewhere classified, other lack of coordination, and need for assistance with personal care. Record review of Resident…
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 before2025-11-21 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences for one (Resident #1) of four residents reviewed for call light placement. The facility failed to ensure Resident #1's call light was within reach. This failure could place residents at risk for needs and accommodation being unmet.Record review of a face sheet dated 11/05/2025 indicated Resident #1 was a [AGE] year-old who was last admitted on [DATE] with multiple diagnoses to include Chronic Obstructive Pulmonary Disease (a long term lung condition that makes it hard to breathe), Memory Deficit, Cerebral Infarction (blood flow to part of the brain was or is blocked, leading to brain cell damage or death), Dysphagia (difficulty swallowing), Cognitive Communication Deficit, Altered Mental Status, and Vascular Dementia (a condition that causes memory, thinking, and reasoning problems due to reduced or blocked blood flow to the brain. Review of a quarterly MDS assessment dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-06-05 · 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
Based on interviews and record review, the facility failed to maintain clinical records that were complete and accurately documented in accordance with accepted professional standards and practices for 4 (100 hall glucometer, 200 hall glucometer, 300 hall glucometer, and 400 hall glucometer) of 8 glucometers (device used to measure the amount of glucose in a resident's blood) reviewed for pharmacy services. 1. The facility failed to ensure the 2 glucometers in the 200-hall nurse cart and 2 glucometers in the 400-hall nurse cart were tested for accuracy and recorded in the glucometer logbook on 06/01/25, 06/02/25 and 06/03/25. 2. The facility failed to ensure the 2 glucometers in the 100-hall nurse cart and 2 glucometers in the 300-hall nurse cart were tested for accuracy and recorded in the glucometer logbook on 06/03/25. These failures could place residents at risk of receiving either too much insulin or not enough. The findings included: Record review of the glucometer logbook on 06/04/25 at 12:47 PM revealed the test results for the 2 glucometers in the 100-hall nurse cart 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 before2025-06-05 · 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 #39) out of 5 residents reviewed for care plans. The facility failed to review or revise Resident #39's care plan after a significant change in condition when Resident #39's code status changed from full code to DNR on [DATE]. This failure could place resident at risk for receiving inadequate care and services. Findings included: Record review of Resident #39's face sheet dated [DATE] revealed a [AGE] year-old male with an original admission date of [DATE] and a current admission date of [DATE]. Diagnoses included Chronic Kidney Disease - Stage 3 (a condition in which the kidneys are damaged and cannot filter blood properly), Type 2 Diabetes (a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-05 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 5 residents (Resident #1) reviewed for wound care. The facility failed to ensure the wound care nurse knew the proper technique for cleansing the venous stasis ulcer during wound care in order to prevent cross-contamination and infection. The deficient practice and failure could place residents at risk for cross contamination, infection, and improper wound healing. Findings included: Record review of Resident #1's face sheet, dated 05/05/25, revealed a [AGE] year-old-male with an original admission date of 05/02/24. Diagnoses included Peripheral Vascular Disease(a disorder of the blood vessels outside the heart which affects circulation), Hemiplegia (severe or complete unilateral loss of strength or paralysis), and Hemiparesis (weakness in one leg, arm or side of face), Type 2…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-05 · 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, interviews, and record reviews, the facility failed to ensure that one (Residents #17) of one resident with an indwelling urinary catheter reviewed received the appropriate treatment and services to prevent Urinary Tract Infection (UTI's): The facility failed to ensure Resident #17 ' s urinary drainage tubing and catheter drainage bag were kept from touching and resting on the floor. This failure could affect any resident with an indwelling urinary catheter and place them at risk of developing or increased UTI's. The findings included: Record review of Resident #17's Face Sheet dated 06/03/25 documented an 82- year-old female admitted [DATE] and re-admitted [DATE] with the diagnoses of: Urine tract infection, Acute Pyelonephritis (kidney infection an illness in one or both kidney organs), and Hydronephrosis (a condition characterized by excess fluid in a kidney due to a backup of urine). Record review of Resident #17's MDS dated [DATE] documented: -Bed mobility: Substantial/maximal…
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 · E2025-04-10 · 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 interviews and record reviews, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 9 of 12 residents (Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, and Resident #10) reviewed for pharmacy services. 1) The facility failed to ensure ADON D disposed of one tablet of Hydrocodone-APAP 10-325 mg by properly including a witness signature on the narcotic sheet when destroyed on 02/28/25 for Resident #2. 2) The facility failed to ensure ADON D disposed of one tablet of Hydrocodone-APAP 10-325 mg by properly including a witness signature on the narcotic sheet when destroyed on 03/04/25 for Resident #3. 3) The facility failed to ensure ADON D disposed of one tablet of Hydrocodone-APAP 10-325 mg by properly including a witness signature on the narcotic sheet when destroyed on 03/04/25 for Resident #4. 4) The facility failed to ensure ADON D disposed…
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 · D2025-04-10 · tag F0553 — failed to let residents help plan their care — isolatedAllow resident to participate in the development and implementation of his or her person-centered plan of care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure residents and/or the residents' representatives the right to participate in the development and implementation of his or her person-centered plan of care for 1 (Resident #1) of 5 residents reviewed for care plans. The facility failed to record any documentation showing any care plan meeting involving Resident #1 or their RP occurred during her stay at the facility from her admission date on 05/29/24 through her discharge date of 12/31/24. This failure could place residents at risk for inadequate care, accidents, and injuries. The findings included: Record review of Resident #1's face sheet dated 04/10/25 revealed an [AGE] year-old female with an initial admission date of 05/29/24 and discharge date of 12/31/24. Pertinent diagnoses included unspecified dementia (loss of cognitive function that interferes with daily life in which the cause was unidentified). Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS…
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 before2025-03-20 · 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 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 4 of 5 residents (Residents #1, #2, #3 and #4) reviewed for infection control practices. 1. The facility failed to ensure the ICP, ADON, DON, staff nurses and CNAs knew the proper placement of PPE carts. 2. The facility failed to ensure PPE carts were posted outside of the EBP rooms of Residents #1, #2, #3 and #4. These failures could place residents at risk of cross contamination and/or infection. Findings include: 1. Record review of Resident #1's face sheet, dated 03/20/25, revealed an [AGE] year-old-female with an original admission date of 10/07/24 and a current admission date of 01/13/2025. Record review of Resident #1's admission MDS, dated [DATE], revealed a BIMS of 02, which indicated severely impaired…
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 before2025-02-27 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriations of resident property, and exploitation for one (Resident #1) of five residents reviewed for abuse. The facility failed to ensure that Resident #1 was free from abuse. On 04/30/24, Resident #2 intentionally pinched Resident #1 on the left arm because Resident #1 put her fingers into Resident #2's cup of ice. Resident #1 sustained bruising from the pinches. Resident #2 was transferred to another facility on 05/01/2025. This failure could place residents at risk for abuse and physical, mental, and psychosocial harm. The findings include: Record review of Resident #1's admission record reflected a [AGE] year-old female that was admitted to the facility on [DATE] with an original admission date of 11/16/20. Resident #1's pertinent diagnoses included Alzheimer's disease with late onset (progressive disease in which brain cells and connections degenerate and die resulting in…
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 19 citations
- Potential for harm · D2025-02-27 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure that licensed nursing staff were able to demonstrate the specific competencies and skill sets necessary to care for resident's needs. The facility failed to ensure LVN-D and LVN-E both were competent in counting their narcotics correctly, as well as competent in keeping control of the narcotic keys appropriately. On 02/26/25 prior to shift change, LVN-D failed to count her narcotics off with LVN-E prior to leaving at the end of her shift, as well as LVN-E failed to secure the narcotic key on her body or person, but left it sitting in a cabinet at the nurses station. This failure had the potential to place residents, visitors, and staff at unnecessary risks of a medication error or drug diversion, to include both the risk of missing or stolen narcotic medications, as well as the risk of missing or stolen narcotic keys. Findings included: Record review of in-service dated 10/29/24 revealed staff were in-serviced over knowing job duties, report must be given, and narcotic log must be done at every shift.…
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 before2025-02-27 · 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 that drugs and biologicals used in the facility were secured and stored in accordance with current accepted professional principles for 2 of 4 medication carts observed for medication storage in that: The facility failed to ensure the 400 hall medication cart and the 100 hall medication cart were locked and/or secured. This failure could place the residents at risk of gaining access to unlocked medications that were not prescribed to them. Findings included: Record review of in-service dated 10/29/24 revealed staff were in-serviced over knowing job duties, report must be given, and narcotic log must be done at every shift. Record review of in-service dated 01/15/25 revealed staff were in-serviced over policies regarding locking med-carts. Observation on 02/26/25 at 8:05 AM revealed an unlocked med-cart parked at the nurse's station with no nurses or other staff around it. There were residents noted to be walking and passing by, as well as a nurse at another med-cart parked at the other side 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 before2024-06-05 · 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 that drugs and biologicals were stored in locked compartments for 2 of 8 medication carts observed for compliance. Two medication carts in the 100 hall were left unlocked and unattended by CMA B. This failure could place residents at risk of access and ingestion of non-narcotic medications. This failure had the potential to affect all 29 residents in the 100 hall. Findings were: Observation on 6/4/2024, at 10:48 a.m., two medication carts were unlocked on hall 100 without a supervised staff in view of both carts. The carts were unlocked for 4 minutes until CMA B exited a room and returned to one (later stated both carts were his carts) of the carts. During an interview on 6/4/2024 at 10:52 a.m., CMA B verbalized both carts that were unlocked were his carts. He verbalized he thought he locked them before entering a room to take a blood pressure on a resident. CMA B stated he was assigned to two medication carts due to a staff member calling in for the shift. CMA B states it is proper process to lock the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-04-12 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 4 Residents ( Resident's #10, #68, #70, and #91) of 9 reviewed for care plans. 1. Resident #10's comprehensive care plan dated 03/23/23 did not reflect he was a smoker nor had a Smoking Safety Screen 2. Resident #68's comprehensive care plan dated 09/28/23 did not reflect she was a smoker nor had a Smoking Safety Screen 3. Resident #70's comprehensive care plan dated 02/27/23 did not reflect he was a smoker nor had a Smoking Safety Screen 4. Resident #91's comprehensive care plan dated 05/11/23 did not reflect he was a smoker nor had a Smoking Safety Screen These deficient practices could place residents at risk of not receiving proper care…
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 before2024-04-12 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, to include providing and obtaining clinical laboratory services to meet the needs of its 28 residents who receive insulin services. The facility failed to keep a log documenting the control solution testing results for the facility's glucometers. This failure could result in not determining if the glucometers were functioning properly and/or obtaining false glucometer readings. The findings included: Record review of the facility's Resident Matrix dated 4/9/24 revealed the facility had 28 resident's who were insulin dependent. Record review of the facility's Blood Glucose Monitoring System User's Guide for Control Solution Testing revealed that the purpose of the control solution testing was to validate that the Meter was working properly with the test strips and that the control solution test should be performed at the following times: When using the meter for the first time When using a new package 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 · E2024-04-12 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen and 1 of 1 nutrition room reviewed for sanitation in that: 1. The facility failed to ensure a juice dispenser gun was sanitary 2. The facility failed to ensure equipment was clean and sanitized 3. The facility failed to ensure dry goods were dated, labeled, and sealed. 4. The facility failed to ensure spices were not left open to the air 5. The facility failed to ensure items in the nutrition room's refrigerator were labeled, dated, and not expired 6. The facility failed to ensure items in the nutrition room were labeled, dated, and not expired 7. The facility failed to ensure the kitchen was following their policies These failures could place residents at risk of foodborne illnesses. Findings included: Observation and initial tour of the kitchen on 04/09/24 beginning at 11:05 AM revealed 2 unlabeled and undated…
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 before2024-04-12 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections, for 3 residents (Resident #13, Resident #29, and Resident #55) of 26 residents that were reviewed for infection control and transmission-based precautions policies and practices, in that: The facility failed to ensure ADON A, HR personnel, and CNA A did not grab resident's' cups and bowls by the rim with bare hands, contaminating the tops of the rims, during the lunch meal serving process. These failures could place residents at risk for infection through cross contamination of pathogens. The findings include: During a lunch dining observation on 04/09/24 at 12:50 PM ADON A, HR personnel, and CNA A were observed touching the rims of the resident's cups and bowls with bare hands during the meal serving process. In an interview on 04/09/24 at 12:54 PM ADON A stated that there is usually not that many…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-12 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to treat residents with respect and dignity for 2 of 6 (Resident #35, and Resident #35)) residents reviewed for resident rights in that: The facility failed to ensure Resident #14, and Resident #35 were treated with dignity in that: Resident #14 and Resident #35's room had a strong odor of urine. Resident #35's floor mat was saturated in urine Resident #35's mattress was saturated in urine, had discoloration, and was stained. Resident #14 and Resident #35's floor was sticky This failure could place residents at risk of feeling uncomfortable, a diminished quality of life, and decline in self-worth. The findings included: 1. Record review of Resident #35's face sheet dated 04/10/2024 with an admission date of 01/04/2023 and an original admission date of 04/05/2022 reflected he was an [AGE] year-old male with diagnoses of dementia, repeated falls, cognitive communication deficit (difficulty with thinking and how someone uses language),…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-12 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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, interviews and record review, the facility failed to ensure each resident had a right to a safem clean, comfortable environment for two (Resident #14, and Resident #35) of six residents reviewed for resident rights. -Resident #14 and Resident #35's room had a strong odor of urine. -Resident #35's floor mat was saturated in urine -Resident #35's mattress was saturated in urine, had discoloration, and was stained. -Resident #14 and Resident #35's floor was sticky This failure could place residents at risk of feeling uncomfortable, a diminished quality of life, and decline in self-worth. The findings included: 1. Record review of Resident #35's face sheet dated 04/10/2024 with an admission date of 01/04/2023 and an original admission date of 04/05/2022 reflected he was an [AGE] year-old male with diagnoses of dementia, repeated falls, cognitive communication deficit (difficulty with thinking and how someone uses language), hypertension, kidney failure, and cerebral infarction (disrupted 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 · D2024-04-12 · tag F0814 — failed to dispose of garbage properly — isolatedDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility must dispose of garbage and refuse properly for 3 of 3 dumpsters (dumpsters A, B, and C) reviewed for garbage disposal. The facility failed to ensure the dumpsters A, B, andC's lids and doors were secured. The facility failed to ensure the dumpsters A, B, and C's were not overflowing This failure could place residents at risk of infection from improperly disposed garbage. Findings included: Observation of the dumpsters A, B, and C on 04/11/24 at 1:04 PM revealed all 3 had the lids open and all 3 were overflowing; one was leaking an unknown liquid onto the ground. In an interview with the MS on 04/11/24 at 2:16 PM, he stated the dumpster doors and sides should have been closed and should not be overflowing at any point because of infection control. The MS stated it was important to keep the lids and doors closed on the dumpsters to keep biohazards from flying out or leaking. The MS stated, The leaking fluid could be tracked back into the building and that's the nasty of the nasty ; gnats, bugs, and rodents could be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-12 · tag F0926 — failed to keep the home smoke-free / fire-safe — isolatedHave policies on smoking.
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, record reviews and interviews the facility failed follow their own established smoking policy for 1 of 9 residents (Resident #30) reviewed for smoking and compliance in that: The facility failed to ensure Resident #30 was wearing a smoking apron the facility implemented as part of their resident's Smoking Policy assessment. This deficient practice could affect residents who smoke and require a smoking apron byand contributeing to a smoking-related injury, fire, and an unsafe smoking environment. The findings were: Record review of Resident #30's Face Sheet dated 04/12/24 reflected an admission date of 05/21/2021 and a readmission date of 9/9/2022. Diagnoses included Dementia (general decline in cognitive abilities that impacts a person's ability to perform everyday activities), schizophrenia (a serious mental disorder in which people interpret reality abnormally), and heart failure. Record review of Resident #30's smoking evaluation dated 03/1/2024 reflected adaptive equipment needed was a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-03-14 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident was free from abuse for 3 of 8 sampled residents (Residents # 8, #22, and #23) reviewed for abuse, in that: Resident #8 was told by CNA X that she could use the restroom by herself and spoke to her very unprofessionally. Resident #8 was left being fearful of falling, and feared retaliation. Residents #22 and #23 both described CNA X as having left them in wet briefs after asking to be changed Leaving Resident #23 feeling humiliated. This failure placed residents at risk of fear, humiliation, and a diminished quality of life. Findings included: Record review of Resident #8's admission record revealed a [AGE] year-old female admitted on [DATE]. Her diagnoses included stroke, high blood pressure, diabetes, difficulty walking, and need for assistance with personal care. Resident #8's MDS dated [DATE] indicated a BIMS of 14 (no cognitive impairment), had no mood disorders or behaviors, was weak on one side due to 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 · E2024-03-14 · tag F0727 — failed to provide required RN coverage — patternHave 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 interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 4 of 74 days reviewed for RN coverage. The facility failed to ensure they had an RN on duty on Sunday, 02/11/24, Sunday, 02/25/24, Saturday, 03/09/24, and Sunday, 03/10/24. This failure could place residents at risk of missed nursing assessments, interventions, and treatment. Findings included: Review of RN staffing for all shifts dated 01/01/24-03/14/24 revealed zero hours worked by an RN on Sunday, 02/11/24, Sunday, 02/25/24, Saturday, 03/09/24, and Sunday, 03/10/24. During an interview with the DON on 03/14/24 at 8:20 am she stated every building had staffing problems, the nurses and herself were working the floors. They were constantly recruiting and hiring, but they (the hires) may come in for one day and never show up again or just never show up at all. The DON stated staffing, recruiting, and retention was also part of their QAPI plan-HR was the lead. The DON stated the facility had recruiting activities and corporate…
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 before2024-01-08 · 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, and interview, the facility failed to ensure that drugs and biologicals used in the facility were secured properly for one of two nurse medication carts (Hall 300 nurse medication cart) and one of one wound care treatment carts (Hall 300) reviewed for drug storage. -Nurse medication cart on Hall 300 was left unlocked and unattended. -Wound Care Treatment cart on Hall 300 was left unlocked and unattended. These deficient practices could place residents at risk for harm to unauthorized people and place the facility at risk for possible drug diversion. Findings include: 1.) Observation on 1/5/2024 at 2:36PM revealed an unlocked and unattended medication cart in the 300 hall for approximately 6 minutes. This surveyor opened the top drawer recognizing the cart being unlocked. A variety of multiple medications in bulk bottles and blister packs were easily assessable for removal. Interview on 1/5/2024 at 2:43PM LVN A stated she had become distracted when she went to assist a resident in the bathroom. LVN A stated all medication carts should be locked at all times 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 · Dcited before2023-10-09 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably 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 interviews and record review, the facility failed to provide services in the facility with reasonable accommodation of resident needs and preferences, for two residents (Resident #1 and Resident #2) of eight residents reviewed for accommodation of needs. 1. The facility did not comply with Resident's #1 request to no longer permit the wound care nurse in his room, after explicitly requesting she no longer be in his room. 2. The facility staff did not provide Resident #2 with a certified professional sign language interpreter, when one was requested days prior to doctor's appointment. This failure could place residents at risk of not having their needs met. Findings included: 1.) Record review of Resident #1's Face Sheet, dated 10/02/2023, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of malignant neoplasm (cancerous tumor), chronic obstructive pulmonary disease (airflow blockage and breathing-related problems), spondylosis (abnormal wear on the cartilage 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 before2023-10-09 · 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 to help prevent the development and transmission of disease and infection for one (Resident #3) of five residents reviewed for infection control, in that: CNA A did not remove her contaminated gloves nor performed hand hygiene after touching multiple surfaces prior to initiating Resident #3's perineal care. These failures could place residents at risk for contamination and infection. The findings included: Record review of Resident #3's Face Sheet dated 10/02/2023 documented an [AGE] year-old female, admitted [DATE], with the following diagnoses of: cerebral infarction (area of brain tissue that dies), hemiplegia (paralysis of one side of the body) and hemiparesis (inability to move on one side of the body), congestive heart failure (heart failure), and dysphagia (swallowing difficulties). Record review of Resident #3's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-17 · 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 person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 4 residents (Resident #1) reviewed for comprehensive care plans in that: The facility did not implement Resident #1's fall prevention interventions documented on Resident #1's comprehensive care plan. This deficient practice could place residents at risk for not receiving appropriate treatment and services. The findings were: Record review of Resident #1's face sheet, dated 08/17/23, revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: Alzheimer's disease, unspecified (a progressive disease that destroys memory and other important mental functions), type 2 diabetes mellitus (high blood sugar) with other 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 · D2023-08-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and hazards. The facility failed to remove a wheelchair from Resident #1's bed side and to provide adequate supervision for Resident #1 for at least 3 hours and 45 minutes while Resident #1 was on the floor. This deficient practice could place the residents at risk for harm, serious injury or death. The findings were: Record review of Resident #1's face sheet, dated 08/17/23, revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: Alzheimer's disease, unspecified (a progressive disease that destroys memory and other important mental functions), type 2 diabetes mellitus (high blood sugar) with other circulatory complications, insomnia (…
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 before2023-08-17 · 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 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 4 Residents (Resident #1) reviewed for medical records accuracy, in that: Resident #1's neurological checks (assessment of sensory neuron and motor responses, especially reflexes, to determine whether the nervous system is impaired) on 02/09/23, 02/21/23 and 03/11/23 were incomplete. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment. The findings were: Record review of Resident #1's face sheet, dated 08/17/23, revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: Alzheimer's disease, unspecified (a progressive disease that destroys memory and other important mental functions), type 2 diabetes mellitus (high blood sugar) with other…
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
$13,397 in federal fines across 1 penalty.
- $13,397 — penalty dated 2024-01-08
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 WELLSENTIAL HEALTH — 67 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 | 2 of 5 | 2.7 | -0.7 vs chain |
| Health inspection | 3 of 5 | 2.9 | +0.1 vs chain |
| Staffing | 1 of 5 | 1.6 | -0.6 vs chain |
| Quality measures | 3 of 5 | 4.2 | -1.2 vs chain |
The other 66 homes this chain runs (chain average 2.7★, per CMS)
Showing 40 of 66; 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 | Since |
|---|---|---|---|
| DEWITT MEDICAL DISTRICT | Organization | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2015 |
| ALEXANDER, ALMA | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER | since 05/27/2020 |
| BAIRD, DANIEL | Individual | MANAGING CONTROL - GOVERNING BODY | since 04/13/2021 |
| CARVAJAL, ANTONIO | Individual | MANAGING CONTROL - GOVERNING BODY | since 05/16/2024 |
| CLAPP, BARBARA | Individual | MANAGING CONTROL - GOVERNING BODY | since 06/01/2021 |
| CORTESE, DAREN | Individual | MANAGING CONTROL - GOVERNING BODY | since 08/10/2021 |
| FRELS, JOHN | Individual | MANAGING CONTROL - GOVERNING BODY | since 11/04/2014 |
| GIBSON, PATRICIA | Individual | MANAGING CONTROL - GOVERNING BODY | since 08/01/2021 |
| GONZALES, VERONICA | Individual | MANAGING CONTROL - GOVERNING BODY | since 05/16/2024 |
| KAUFMAN, NICOLE | Individual | MANAGING CONTROL - GOVERNING BODY | since 08/10/2021 |
| MANDELBAUM, ELLIOT | Individual | MANAGING CONTROL - GOVERNING BODY | since 01/01/2025 |
| PAPACEK, CHARLES | Individual | MANAGING CONTROL - GOVERNING BODY | since 10/01/1997 |
| SHEPPARD, ANNA | Individual | MANAGING CONTROL - GOVERNING BODY | since 05/01/2019 |
| SHEPPARD, CYNTHIA | Individual | MANAGING CONTROL - GOVERNING BODY | since 06/25/2013 |
| REGENCY IHS OF CORPUS CHRISTI LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2015 |
| REGENCY IHS REHAB LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2015 |
| REGENCY INTEGRATED HEALTH SERVICES LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2015 |
| CAMPBELL, STUART | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/10/2024 |
| DEKOWSKI, DONOVAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2015 |
| 2735 AIRLINE ROAD LLC | Organization | ADP OF THE SNF | since 01/01/2015 |
| CSV RHEA MANAGEMENT HOLDCO, LLC | Organization | ADP OF THE SNF | since 01/01/2015 |
| DWD TX HOLDINGS LLC | Organization | ADP OF THE SNF | since 01/01/2015 |
| JACK AND NANCY DWYER WORKFORCE DEVELOPMENT CENTER INC | Organization | ADP OF THE SNF | since 01/01/2015 |
| REG HG OPCO 1, LLC | Organization | ADP OF THE SNF | since 01/01/2015 |
| REG HG OPCO LLC | Organization | ADP OF THE SNF | since 01/01/2015 |
| REG OPERATOR HOLDCO LLC | Organization | ADP OF THE SNF | since 01/01/2015 |
| REGENCY IHS CLINICAL CONSULTING, LLC | Organization | ADP OF THE SNF | since 01/01/2015 |
| REGENCY IHS MASTER TENANT LLC | Organization | ADP OF THE SNF | since 01/01/2015 |
| REGENCY TEXAS HOLDINGS LLC | Organization | ADP OF THE SNF | since 01/01/2015 |
| AHMAD, SHAHAB | Individual | ADP OF THE SNF | since 01/01/2025 |
| PENA, NICOLE | Individual | ADP OF THE SNF | since 01/01/2025 |
| RODRIGUEZ, MONICA | Individual | ADP OF THE SNF | since 01/01/2025 |
CMS files one row per role, so the 40 rows in the source record cover these 32 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.
14 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.
About 81% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself.
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 676107. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-05, 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.