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Corrigan LTC Partners

300 Hyde St, Corrigan, TX 75939 · Government - Hospital district · 86 certified beds · (936) 398-2220 Medicare & Medicaid certified

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Abuse/neglect citations on record (F0600, F0602, F0607) — most recent Aug 20241 immediate-jeopardy citation2 immediate-jeopardy citations CMS recorded as corrected before the inspection ended (past non-compliance)$91,839 in federal fines
Insights

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

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has abuse, neglect, or exploitation citations (F0600, F0602, F0607) — most recent Aug 2024
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • 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 (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $91,839 in federal fines (most recent 2025-07-25)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • its facility-reported quality-measure rating is low (1/5)
  • nursing-staff turnover (64%) runs well above the national median (45%)

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

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

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

Location & what’s nearby

Urgent care / clinic
900 S Temple Dr · (936) 829-5501 · Call to confirm hours
Pharmacy
100 S Home St · (936) 398-9227 · Call to confirm hours
Grocery
100 S Home St · (936) 398-4704 · Call to confirm hours
Park
US HWY 287W, W, W 2nd St · Typically dawn to dusk
Place of worship
305 W Front St · (936) 398-2269

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 1 of 5
Long-stay residentspeople who live here 1 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.

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

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased18.3%15.8%15.4%worse
Long-stay residents who lose too much weight5.3%3.0%5.4%typical
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection2.6%0.8%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.9%2.4%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury8.2%3.3%3.3%worse
Long-stay residents whose ability to walk worsened16.1%14.0%16.1%typical
Long-stay residents on antianxiety or hypnotic medication21.8%18.0%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers5.0%3.8%4.7%typical
Long-stay residents with worsening bladder/bowel control15.9%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table28.8%9.6%17.1%worse
Short-stay residents who newly got an antipsychotic medication6.2%1.5%1.4%worse
Short-stay residents rehospitalized after admission37.5%25.7%22.6%worse
Short-stay residents with an outpatient ER visit16.3%12.3%12.0%worse
Long-stay hospitalizations per 1,000 resident days3.152.171.67worse
Long-stay outpatient ER visits per 1,000 resident days3.252.061.80worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

10.2%U.S. median 10.7%
Went back to hospital
0.27U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy

Therapy staffing: this home’s payroll records show 0.27 therapist hours per resident per day in 2026Q1 — more than 40% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.2%CMS range 6.6–15.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot 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 next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.1%CMS range 3.2–11.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.221.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.42
RN hours/ resident / day
1.20
LPN hours/ resident / day
2.09
Aide hours/ resident / day
3.71
Total nurse hours/ resident / day
0.40
RN hoursweekends
63.6%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 86 beds and averages 41.5 residents a day — about 48% occupied, or roughly 44 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 3.71 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.42 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.09 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.33 hrs/resident/day on weekends vs 3.86 on weekdays — 14% thinner on weekends. RN hours go from 0.42 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 64% is well above 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

6
deficiencies at the latest standard inspection (2025-09-17)
10
at the previous standard inspection (2024-08-28)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

30 citations, most serious first. The 14 most serious are shown; the remaining 16 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2025-07-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #1) reviewed for supervision to prevent elopement. RN A failed to ensure Resident #1's wander guard (a device designed to prevent wandering in the elderly) was functioning as required. The facility was unaware that on [DATE], Resident #1 eloped from the facility with a wander guard sometime after 8:15 p.m. (approximately) and was found on the ground at an apartment complex adjacent to the facility by EMS at approximately 10:30 p.m. Resident #1 was returned to the facility by EMS on [DATE] at approximately 10:45 p.m. An IJ was identified on [DATE] at 1:45 p.m. While the IJ was removed on [DATE] at 1:30 p.m., the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm due to the facility'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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · Jcited before2023-11-14 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 residents were free from abuse for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed to prevent Resident #1 from grabbing, hitting and slapping Resident #2 on 11/03/23 . The noncompliance was identified as PNC. The immediate jeopardy (IJ) began on 11/03/23 and ended on 11/08/23. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of physical harm, mental anguish, emotional distress, or death. Findings included: Record review of Resident #1's face sheet indicated she was a [AGE] year old female admitted on [DATE] and her diagnoses included Alzheimer's (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with behavioral disturbance,…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Immediate jeopardy · J2023-11-14 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    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 implement policy to ensure the rights of residents to be free from abuse for 1 of 6 residents (Resident #2) reviewed for abuse. The facility failed to prevent Resident #1 from grabbing, hitting and slapping Resident #2 on 11/03/23. The noncompliance was identified as PNC. The immediate jeopardy (IJ) began on 11/03/23 and ended on 11/08/23. The facility had corrected the noncompliance before the survey began. The failure could place residents at risk for abuse, intimidation, fear, agitation, and decreased quality of life. Findings included: Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 2001 indicated Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This included but is not limited to freedom from corporal punishment, involuntary seclusion verbal, mental, sexual, or physical abuse and physical or chemical restraint not required to…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Actual harm · Gcited before2024-08-01 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 8 residents (Resident #1) reviewed for abuse. The facility failed to ensure CNA A did not verbally and physically abuse Resident #1 when she yelled, cursed and aggressively removed the resident's clothes, on 05/17/2024. This failure could place residents at risk for emotional distress, fear, decreased quality of life and further abuse. Findings included: Record review of Resident #1's face sheet, dated 07/29/2024, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included type 2 diabetes (a chronic condition that affects the way the body processes blood sugar), hypothyroidism (condition where the thyroid doesn't create and release enough thyroid hormone into your bloodstream), schizophrenia (mental health condition with a combination of symptoms of schizophrenia 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-19 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 out of 5 (Resident #1 and Resident #2) residents reviewed for enhanced barrier precautions (EBP) for infection control practices. 1. Hospice Aides A and B failed to put on EBP while providing ADL care for Resident #1 on 05/18/26.2. The facility did not implement EBP for Resident #2 after she returned to the facility with a surgical wound on 05/13/26. These failures could place residents at risk for cross contamination and the spread of infection.The findings included: 1.Record review of Resident #1's face sheet dated 05/19/26 indicated she was an [AGE] year old female, admitted on [DATE] and her diagnoses included chronic kidney disease (long term condition where kidneys gradually lose function), unspecified disorder 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-06 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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, which 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 7 residents (Resident #1) reviewed for care plans. The facility failed to develop and implement Resident #1's care plan for behavior towards other residents after he hit Resident #2 with a fly swatter on 11/18/25. This failure could place residents at risk of further incidents of aggression. Findings included: Record review of Resident #1's face sheet dated 01/07/25 indicated he was a [AGE] year old male admitted on [DATE] and his diagnoses included hemiplegia (severe paralysis) and hemiparesis (muscle weakness) following cerebral infarction (stroke) affecting left dominant side, intermittent explosive disorder (mental health condition characterized…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-09-17 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: 1. Expired milk was not disposed of.2. Hairnets were not worn properly. 3. Meat was not thawed properly in the sink. These failures could place residents who received meals from the kitchen at risk for food borne illness. During an observation on 9/15/2025 at 8:20 a.m. while in the kitchen it was observed that a tube of hamburger beef was not being thawed properly. Hamburger meat was in a kitchen sink, submerged in hot water with no water continuously agitating the surface of the water. The water was steaming and hot to the touch. It was observed that a gallon of milk was out of date, September 13th, 2025. This milk was stored in an ice chest with mostly melted ice. During an observation on 9/15/2025 at 12:12 p.m., in the dining room it was observed that [NAME] E did not have all of her hair in a hairnet. [NAME] E hair went down her back 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-17 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to treat each resident with respect and dignity in an environment that promoted maintenance or enhancement of his or her quality of life for 2 of 14 residents (Resident #3 and Resident #18) reviewed for resident rights. The facility failed to protect and value Resident #3 and Resident #18's dignity when their catheter urine collection bags either did not have a privacy bag on it or it was not properly placed on the catheter bag. This failure could place residents at risk for decreased quality of life, increased anxiety, embarrassment and increased stress. Findings included:1. Record review of Resident #3's admission Record dated 8/15/25 indicated he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Streptococcal Sepsis (a life-threatening infection caused by bacteria known as Streptococcus), Muscle Weakness (Muscle weakness can have causes that aren't due to underlying disease. Examples include poor…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-17 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 1 of 5 residents (Resident #35) reviewed for unnecessary medications. The facility failed to ensure Resident #35 had an appropriate rationale for declining a gradual dose reduction for her Lexapro (antidepressant medication) and Seroquel (an antipsychotic medication) medications. This failure could put residents at risk of possible psychotropic medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications.Record review of Resident #35's face sheet, dated 09/16/25, indicated she was a [AGE] year-old female, originally admitted to the facility on [DATE], and most recently readmitted on [DATE]. Her diagnoses included anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the resident environment remained free of accident hazards for 2 of 14 residents (Resident #3 and Resident #31) reviewed for accidents and hazards.1. The facility failed to keep prohibited items, Povidone-Iodine 10% solution, out of Resident #3's room.2. The facility failed to keep prohibited items, chemical cleaning solution, out of Resident #31's room.This failure could place residents at risk for injury, harm, and impairment or death.This failure could place residents at risk for injury, harm, and impairment or death.Findings included:1. Record review of Resident #3's admission Record dated 8/15/25 indicated he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Streptococcal Sepsis (a life-threatening infection caused by bacteria known as Streptococcus), Muscle Weakness (Muscle weakness can have causes that aren't due to underlying disease. Examples include poor physical conditioning, intense…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-17 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 13 residents (Resident #28) reviewed for pharmacy services. The facility failed to ensure that 8 tablets of Resident #28's prescribed morphine (opiate pain medication) were properly accounted for and not missing on 09/15/25. This failure could place residents at risk for decreased quality life and unrelieved pain.Findings included: Record review of Resident #28's face sheet, dated 09/16/25, indicated she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions.), peripheral vascular disease (a slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel) and poly-osteoarthritis (characterized by the degeneration of cartilage and the underlying bone…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-17 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 15 residents reviewed for infection control practices (Resident #38). The facility failed to ensure CNA A changed her gloves and performed hand hygiene appropriately while providing incontinent care to Resident #38. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections. Findings included: Record review of Resident #38's undated face sheet indicated she was a [AGE] year-old-female that admitted [DATE], with a readmit date of 7/9/23. Record review of the physician's orders dated 9/16/25 indicated Resident #38 had diagnoses that included: hypertension (the force of blood against the arterial walls is too high), diabetes (the body cannot properly…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-25 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received an accurate assessment, reflective of the resident's status for 2 of 7 residents (Residents #1 and #3) reviewed for accuracy of assessments. The facility did not accurately complete the MDS assessment to indicate Resident #1 eloped from the facility on 06/02/25. The facility did not accurately complete the MDS assessment to indicate Resident#3 displayed physical aggression toward another resident on 06/27/25. Findings included: Record review of Resident #1's face sheet dated 07/24/25 indicated she was an [AGE] year old female, admitted on [DATE], and her diagnoses included unspecified psychosis (indicates the presence of psychotic symptoms that don't perfectly align with a specific diagnosis), lack of coordination (a condition characterized by difficulty in performing physical movements smoothly and accurately), vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-08-28 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections were maintained for the facility for 1 of 2 residents reviewed for isolation during med pass. The facility failed to ensure LVN G used enhanced barrier precautions while she administered medication for Resident #4 per gastrostomy tube ((g-tube) a tube inserted through the belly that brings nutrition directly to the stomach). This failure could place residents at risk for exposure to infections and communicable diseases. Findings included: 1. Record review of Resident #4's admission sheet dated 08/25/24 indicated she was admitted on [DATE] and was [AGE] years old with diagnoses of dysphagia (difficulty in swallowing). Record review of Resident #4's physician's orders dated August 2024 indicated her orders included NPO (nothing by mouth), was to…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · E2024-08-28 · tag F0941 — pattern
    Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure employees received the required training effective communications mandatory training was completed for 4 of 4 new employees (LVN A, LVN B, CNA C, and CNA D) reviewed for training. The facility did not ensure effective communication training was completed by LVN A, LVN B, CNA C, and CNA D during orientation. This failure could place residents at risk of miscommunication and social isolation due to lack of staff training. Findings included: Record review of employee files indicated the following staff had not completed effective communications training during orientation: * LVN A, hire date 03/29/24; * LVN B, hire date 04/22/24; * CNA C, hire date 07/25/24; and * CNA D, hire date 05/09/24. During an interview on 08/28/24 at 09:41 a.m. the BOM/HR said the communication training was not included in the Required Orientation Trainings in the computer system, so it was not done during the orientation time period for LVN A, LVN B, CNA C, and CNA D. During an interview on 08/28/24 at 01:05 p.m. the Administrator said she…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-28 · tag F0943 — pattern
    Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure employees received the required training on dementia management for 2 of 2 new employees (LVN A and LVN B) reviewed for orientation training. The facility did not ensure dementia management training was completed by LVN A and LVN B during orientation. This failure could place residents with dementia at risk of a poor quality of care by staff with inadequate training when caring for dementia residents. Findings included: Record review of employee files indicated the following staff had not completed dementia management training during orientation: * LVN A, hire date 03/29/24; and * LVN B, hire date 04/22/24. During an interview on 08/28/24 at 09:41 a.m. the BOM/HR said LVN A and LVN B had not done the dementia management training during the orientation time period. She said she had missed that it was not completed. During an interview on 08/28/24 at 01:05 p.m. the Administrator said she expected all new hire staff to have the required training done prior to working. She said the possible negative outcome 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-28 · tag F0944 — pattern
    Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program was completed for 4 of 4 new employees (LVN A, LVN B, CNA C, and CNA D) reviewed for orientation training. The facility did not ensure QAPI training was completed by LVN A, LVN B, CNA C, and CNA D during their orientation. This failure could place staff and residents at risk for not being aware of facility programs, implementation, and monitoring. Findings included: Record review of employee files indicated the following staff had not completed QAPI training during orientation: * LVN A, hire date 03/29/24; * LVN B, hire date 04/22/24; * CNA C, hire date 07/25/24; and * CNA D, hire date 05/09/24. During an interview on 08/28/24 at 09:41 a.m. the BOM/HR said the QAPI training was not included in the Required Orientation Trainings in the computer system, so it was not done during the orientation time period prior to working for LVN A, LVN B, CNA C, and CNA D. She said…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-28 · tag F0946 — pattern
    Provide training in compliance and ethics.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure compliance and ethics training was completed for 4 of 4 new employees (LVN A, LVN B, CNA C, and CNA D) reviewed for orientation training. The facility did not ensure compliance and ethics training was completed by the LVN A, LVN B, CNA C, and CNA D during orientation. This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training. Findings included: Record review of employee files indicated the following staff had not completed compliance and ethics training during orientation: * LVN A, hire date 03/29/24; * LVN B, hire date 04/22/24; * CNA C, hire date 07/25/24; and * CNA D, hire date 05/09/24. During an interview on 08/28/24 at 09:41 a.m. the BOM/HR said the ethics and compliance training was not included in the Required Orientation Trainings in the computer system, so it was not done during the orientation time period prior to working for LVN A, LVN B, CNA C, and CNA D. She said she had missed that it was not completed. During an interview on 08/28/24 at…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-28 · tag F0947 — failed to train nurse aides adequately — pattern
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure CNAs completed dementia management training for 2 of 2 new CNAs (CNA C and CNA D) reviewed for orientation training. The facility did not ensure dementia management training was completed by CNA C and CNA D during orientation. This failure could place residents with dementia at risk of abuse, neglect, and exploitation and a poor quality of care by staff with inadequate training when caring for dementia residents. Findings included: Record review of employee files indicated the following had not completed dementia management training during orientation: * CNA C, hire date 07/25/24; and * CNA D, hire date 05/09/24. During an interview on 08/28/24 at 09:41 a.m. the BOM/HR said the dementia management training was not included in the Required Orientation Trainings in the computer system, so it was not done during the orientation time period prior to working for CNA C and CNA D. She said she had missed that it was not completed. During an interview on 08/28/24 at 01:05 p.m. the Administrator said she expected all new…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-28 · tag F0949 — failed to train staff on dementia and abuse — pattern
    Provide behavior health training consistent with the requirements and as determined by a facility assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure training on behavioral health was completed for 4 of 4 new employees LVN A, LVN B, CNA C, and CNA D) reviewed for orientation training. The facility did not ensure behavioral health training was completed by LVN A, LVN B, CNA C, and CNA D during orientation. This failure could place residents with behaviors at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training. Findings included: Record review of employee files indicated the following staff had not behavioral health training during orientation: * LVN A, hire date 03/29/24; * LVN B, hire date 04/22/24; * CNA C, hire date 07/25/24; and * CNA D, hire date 05/09/24. During an interview on 08/28/24 at 09:41 a.m. the BOM/HR said the behavioral health training was not included in the Required Orientation Trainings in the computer system, so it was not done during the orientation time period prior to working for LVN A, LVN B, CNA C, and CNA D. She said she had missed that it…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-28 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    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 receiving enteral feeding received appropriate care and services to prevent complication of enteral feeding for 1 of 2 resident (Resident #4) reviewed for enteral feeding. The facility failed to ensure LVN G flushed Resident #4's gastrostomy tube (g-tube) (a tube inserted through the belly that brings nutrition directly to the stomach) with 30 cc water before and after medication by gravity. The failure could place residents receiving enteral nutrition and medications at increased risk of not receiving proper nutrition, infection, aspiration (breathing in a foreign object into the lungs), and possible injury. Findings included: Record review of Resident #4's admission sheet dated 8/25/24 indicated she was admitted on [DATE] and was [AGE] years old with diagnoses of dysphagia (difficulty in swallowing). Record review of Resident #4's physician's orders dated August 2024 indicated her orders included NPO (nothing by…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-28 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assured the accurate administering of medications for 1 of 14 residents reviewed for pharmaceutical services. (Resident #37) The facility did not administer Peridex mouthwash to Resident #37 twice daily as ordered by her physician. This failure could place the residents at risk of mouth infections and gum inflammation. Findings included: Record review of physician orders dated August 2024 indicated Resident #37, admitted [DATE], was a [AGE] year-old female with diagnoses of Parkinson's disease (a disorder of the central nervous system that affects movement, often leading to tremors) and cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). She was to receive Peridex mouth/throat solution 0.12% 15 ml by mouth two times a day related to specified prophylactic (intended to prevent disease) measures for 14…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-28 · tag F0942 — isolated
    Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure the rights of the resident and responsibilities of the facility were completed for 1 of 4 new employees (CNA C) reviewed for orientation training. The facility failed to ensure the rights of the resident and responsibilities of the facility training was completed by CNA C during orientation. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. Findings include: Record review of employee files indicated CNA C, hire date 07/25/24 had not completed Resident Rights training during orientation. During an interview on 08/28/24 at 09:41 a.m. the BOM/HR said CNA C had not done the Resident Rights training during the orientation time period prior to working. She said she had missed that it was not completed. During an interview on 08/28/24 at 01:05 p.m. the Administrator said she expected all new hire staff to have the required trainings done prior to working. She said the possible negative outcome could be staff would not know procedures for resolving issues 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-01 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to immediately inform the resident, consult with the resident's physician, notify, consistent with his or her authority, the resident's representative(s) when there was an accident involving the resident which resulted in injury and had the potential for requiring physician intervention for 1 of 10 residents reviewed for notification of changes. The facility failed to notify the responsible party (FM G) and physician for Resident #2 when she fell causing pain to her knee while ambulating up the steps of the transport van on 6/12/2024. This failure could place residents at risk for a decline in health, and for family members not knowing the health status of the resident, being informed of and participating in care decisions. Findings include: Record review of Resident #2's face sheet, dated 07/29/2024, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included cerebral infarction (lack of adequate…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-01 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation to include but not limited to freedom from corporal punishment, involuntary seclusion and any physicial or chemical restraint not required to treat the resident's medical symptoms for 1 of 7 residents (Resident #3) reviewed for misappropriation and exploitation. The facility failed to ensure CNA Student D did not steal Resident #3's personal information and attempt to obtained multiple car loans and fast cash with Resident #3's personal information. This failure could place residents at risk of left of money, identity theft, unauthorized or coerced purchases from resident's funds, and feelings of loss. The findings include: Record review of Resident #3's face sheet, dated 07/29/2024, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included angina pectoris (chest pain or…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-01 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency an d adult protective services where state law provides jurisdiction in long-term care facilities, in accordance with State Law though established procedures for 1 of 8 residents (Resident #1) reviewed for abuse. CNA B failed to immediately report verbal abuse to the Administrator when she overheard CNA A verbally abuse Resident #1 on 05/17/2024 at 9:00 p.m. This failure could place residents at risk for further abuse and neglect. Findings include: Record review of Resident #1's face sheet, dated 07/29/2024,…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-14 · tag F0622 — isolated
    Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a discharge was appropriately communicated and documented in the medical record for 1 of 1 discharged resident (Resident #1) reviewed for discharge requirements. The facility discharged Resident #1 to home on [DATE]. Resident #1's clinical record had no physician documentation to address why resident was being discharged , what needs of the resident the facility could not meet, and how the resident posed a danger to the existing resident population. The noncompliance was identified as PNC. The noncompliance began on 11/03/23 and ended on 11/08/23. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for inappropriate discharge from the facility. Findings included: Record review of Resident #1's face sheet indicated she was a [AGE] year old female admitted on [DATE] and her diagnoses included Alzheimer's (a progressive disease beginning with mild memory loss and possibly leading to loss…

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

    Resident Rights Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2023-11-14 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 6 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's care plan included supervision and interventions after she returned to the facility from a behavioral hospital with continued aggressive behaviors on 10/31/23. Resident #1's care plan did not include discharge plans for 11/03/23. This failure could place residents at risk of being physically assaulted due to lack of appropriate interventions in place. Findings included: Record review of Resident #1's face sheet indicated she was a [AGE] year old female admitted on [DATE] and her diagnoses included Alzheimer's (a progressive disease beginning with mild memory…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-06-28 · tag F0727 — failed to provide required RN coverage — pattern
    Have 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 (RN) for at least 8 consecutive hours a day, 7 days a week for 4 of 4 months reviewed. (January 2023, February 2023, March 2023, and June 2023) The facility did not have the required 8 consecutive hours of RN coverage during the months of January 2023 (4 days), February 2023 (2 days), March 2023 (2 days), and June 2023 (3 days). This failure could place residents at risk for not having their nursing care and medical needs met. Findings include: Record review of the January 2023 time sheets indicated no RN worked on Monday 01/02/23, Sunday 01/15/23, Monday 01/16/23 and Tuesday 01/17/2023. Record review of the February 2023 time sheets indicated no RN worked on Saturday 02/04/2023 and Sunday 02/19/2023. Record review of the March 2023 time sheets indicated no RN worked on Tuesday 03/14/2023 and Saturday 03/25/2023. Record review of the June 2023 time sheets indicated no RN worked on Saturday 06/10/2023, Sunday 06/11/2023, and Saturday 06/24/2023. During an interview on 06/28/2023 at…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-06-28 · tag F0868 — pattern
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure that the facility's Medical Director attended the Quality Assessment and Assurance/Quality Assurance and Performance Improvement Committee meetings, for 2 of 2 quarterly meetings (April, May, June 2022 and July, August, September 2022), reviewed for QAA/QAPI. The facility failed to ensure the Medical Director attended their QAA and QAPI meetings for the months of April 2022 through September 2022. This failure could place residents at risk for quality deficiencies being unidentified and no appropriate plans of actions developed or implemented, and no appropriate guidance developed. Findings included: Review of the facility's QAA/QAPI meeting signature logs for the months of April 2022 through September 2022, revealed the Medical Director had not attended any of the meetings for the QAA/QAPI Committee, during those months. There were no notation indicating the Medical Director had attended any of the meetings by telephone or zoom. During an interview on 06/28/2023 at 1:35 PM, the Administrator said the QAA/QAIP met…

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

    Administration Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$91,839 in federal fines across 4 penalties.

  • $14,901 — penalty dated 2025-07-25
  • $31,000 — penalty dated 2024-08-01
  • $22,969 — penalty dated 2023-11-14
  • $22,969 — penalty dated 2023-11-14

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

Part of a chain

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

RatingThis homeChain avg
Overall 1 of 52.4-1.4 vs chain
Health inspection 2 of 53.0-1.0 vs chain
Staffing 2 of 51.6+0.4 vs chain
Quality measures 1 of 52.6-1.6 vs chain
The other 19 homes this chain runs (chain average 2.4★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleSince
EAST TEXAS III ASSOCIATES, LLCOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 01/01/2023
MURRELL, EDWARDIndividualCORPORATE OFFICERsince 01/01/2023
CORRIGAN LTC PARTNERS, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2023
BERGERON, BOBBYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2023
NICHOLSON, LOUISIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2023
JEFFERSON, LORINEIndividualADP OF THE SNFsince 10/01/2024
SPLENSER, PABLOIndividualADP OF THE SNFsince 10/01/2024

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

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

Follow the money — this home’s finances

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

$3.8M
Net patient revenuemost recent cost report
-5.4%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 64%Medicare 10%Other / private 26%

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

$216per resident / day
operating cost
$6,561per month
≈ monthly operating cost
$205per day
avg. revenue, all payers

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

What families pay in TX

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 676072. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-17, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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