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Meadows of Corsicana, LLC

3301 W. Park Row Blvd, Corsicana, TX 75110 · For profit - Limited Liability company · 96 certified beds · (903) 872-2455 Medicare & Medicaid certified

Call the home — (903) 872-2455 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0602) — cited Sep 2023
Insights

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

In its favor
  • a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0602), cited Sep 2023
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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.

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 5 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
301 Hospital Dr · (214) 821-3591 · Call to confirm hours
Pharmacy
3801 W State Highway 31 · (903) 874-8239 · Call to confirm hours
Grocery
Aldi0.4 mi
3623 W State Highway 31 · (855) 955-2534 · Call to confirm hours
Park
621 S 44th St · (903) 874-1500 · Typically dawn to dusk
Place of worship
3245 W 7th Ave · (903) 874-3167

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 4 of 5
Short-stay residentsrehab / post-hospital 3 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 5 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 rating5★
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 increased16.8%15.8%15.4%typical
Long-stay residents who lose too much weight3.1%3.0%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.6%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.6%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 injury2.9%3.3%3.3%better
Long-stay residents whose ability to walk worsened10.6%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication14.1%18.0%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers1.9%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control13.5%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table16.9%9.6%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine90.0%88.0%79.4%better
Short-stay residents rehospitalized after admission34.2%25.7%22.6%worse
Short-stay residents with an outpatient ER visit30.0%12.3%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.512.171.67worse
Long-stay outpatient ER visits per 1,000 resident days2.642.061.80worse

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.

0.51U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.35hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.51 therapist hours per resident per day in 2026Q1 — more than 82% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% 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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
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 identified95.5%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.721.02Oct 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

0.86
RN hours/ resident / day
0.60
LPN hours/ resident / day
2.20
Aide hours/ resident / day
3.65
Total nurse hours/ resident / day
0.86
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 96 beds and averages 44.8 residents a day — about 47% occupied, or roughly 51 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 3.65 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.86 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.20 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 3.09 hrs/resident/day on weekends vs 3.88 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.86 to 0.86 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

3
deficiencies at the latest standard inspection (2025-10-02)
4
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.

23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.

  • Potential for harm · Ecited before2025-10-02 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility did not store, cook, and give out food in a safe and clean way for 1 of 1 kitchen for kitchen task.The facility failed to ensure food safety by not consistently monitoring, discarding, labeling, and storing food items in the refrigerator and storage areas.These failures could place residents at risk for food-borne illness. Findings included: In the observation on 9/30/2025 9:10AM of the initial walk through of kitchen revealed the following: -Dried egg noodles with open date 6/1/2025 and expiration date 9/1/2025-Dried ziti noodles with open date of 6/2/2025 expiration date 9/2/2025-Dried spaghetti in a plastic bag that was not sealed properly. In the walk-in refrigerator: -A personal size of pudding was fully covered in a bowl. There was no label indicating what the dish contained, the date it was prepared, or the date it should be consumed by. -A plastic storage container of leftover chicken noodle soup. The container was not labeled with its…

    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 · Ecited before2025-10-02 · 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 establish and maintain an infection control program for 6 (Resident #56, Resident #47, Resident #51, Resident #21, Resident #35 and Resident #8) of 10 residents reviewed for infection control. 1. CNA D did not conduct hand hygiene between residents (Resident #56, Resident #47, Resident #51, Resident #21, and Resident #35) when passing hallway lunch trays. 2. CNA E did not conduct hand hygiene and glove change when performing peri-care when going from front to back and pulled adult wipes from the package with soiled gloves when providing peri-care for Resident #8. These failures could place the residents at risk of transmission of disease and infection and re-hospitalization. Findings included: Observation on 09/30/25 at 12:16 PM of hallway lunch tray pass with CNA D, said she did not conduct hand hygiene when passing a lunch tray to Resident #47's room. CNA D then took a lunch tray to Resident #56's room, and no hand hygiene was conducted.…

    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 before2025-10-02 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure 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 make sure that drugs are stored properly, and only authorized persons have access for 1 of 4 medication carts (MC A) reviewed for drug storage and labeling. The facility failed to ensure the F-hall medication cart was locked and medications were secured and not accessible to other staff, residents, or visitors. This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications.Findings included:Observation of F-hall on 09/30/2025 at 9:05 a.m., revealed MC A was unattended and unlocked. LVN A was in room F50. The medication cart was partially in front of room F50. The locking mechanism was protruding outward on the medication cart. The state surveyor opened drawers and captured pictures. LVN A was in the room with a resident with the privacy curtain pulled closed. During an interview on 09/30/2025 at 9:10am, LVN A stated she was trained on medication storage. She said the policy was to make sure the narcotics were locked, 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-08-28 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 the facility's only kitchen in that: The facility failed to ensure expired milk in the walk-in refrigerator was discarded in a timely manner. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included: In an observation on 8/26/24 at 10:02 AM, revealed one-gallon of milk that was half-filled had best-by date of 8/19/24 in the facility's walk- in refrigerator. In an interview with the Dietary Manager on 8/26/24 at 10:06 AM, revealed she conducted morning walk-in rounds every Monday to check for expired products since new inventory was delivered every Tuesday. She further added she had forgotten to conduct her morning rounds on Monday, 8/26/24. She stated that the use-by date on the milk gallon was…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-28 · tag F0635 — isolated
    Provide 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 observation, interview, and record review, the facility failed to ensure that residents had physician's orders for the resident's immediate care for one (Resident #3) of six residents observed for physician orders for oxygen. The facility failed to provide physician orders for Resident #3, while resident was on oxygen 2 liters via nasal cannula. These failures could place the residents at risk of not receiving necessary care and services that could result to worsen condition. Findings included: Review of Resident #3's Face Sheet dated 08/27/2024 reflected that resident was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Relevant diagnoses included pleural effusion (fluid accumulation around the lungs), muscle weakness, dyspnea (the sensation of difficult or uncomfortable breathing), and hypertension (elevated blood pressure). Review of Resident #3's MDS assessment dated [DATE] reflected that Resident #3 had an intact cognition with a BIMS score of 15. 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-28 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #18) of 6 residents reviewed for quality of life. The facility failed to ensure Resident #18 had her fingernails and facial hair trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings included: Record review of Resident #18's Quarterly MDS assessment dated [DATE] reflected Resident #18 was an [AGE] year-old female with initial admission date to the facility on 1/17/2019. Resident #18's relevant diagnoses included Anemia, Hypertension, Renal insufficiency, hyperlipidemia, anxiety disorder, senile degradation of brain, severe stage bilateral Glaucoma. Resident #18 needed substantial assistance for bathing and needed setup assistance with ADLs. Resident #18 had…

    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 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 maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #42) of six residents observed for infection control. CNA B failed to perform hand hygiene between glove changes, and when she went from dirty to clean during incontinence care for Resident #42. These failures placed residents at risk for spread of infection through cross-contamination. Findings included: Record review of Resident #42's face sheet dated 08/27/2024 reflected she was [AGE] years old female. She was originally admitted to the facility on [DATE] and readmitted on [DATE]. She was admitted with the diagnoses of diabetes mellitus, hypertension (high blood pressure), morbid obesity. Review of Resident#42's MDS assessment dated [DATE] reflected Resident#42 had an intact cognition with a BIMS score of 15.…

    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 · D2023-09-22 · 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 misappropriation of resident property for 1 of 6 residents (Resident #1) reviewed for misappropriation of property. The facility failed to prevent misappropriation of property when Housekeeper A charged Resident #1 $10 for gas to purchase items from the store. This failure could place residents at risk of misappropriation which could lead to further exploitation of other residents. Findings include: Review of Resident #1's face sheet dated 09/22/23, documented a [AGE] year-old female admitted to the facility 04/12/23 with diagnoses that included chronic obstructive pulmonary disease (a chronic lung disease that causes obstructed airflow from the lungs), muscle wasting and atrophy (loss of muscle tissue), type 2 diabetes mellitus without complications, hypertensive heart disease with heart failure (systolic or diastolic heart failure, conduction arrhythmias, especially atrial fibrillation, and increase risk…

    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 · D2023-09-22 · 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 interview and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications for 1 of 1 resident reviewed for enteral nutrition (Resident #2). LVN A failed to follow the physician orders for enteral feedings on 09/07/23 at 6:00pm (a form of nutrition that is delivered into the digestive system as a liquid form via the feeding tube) for Resident #2. This failure could affect residents receiving enteral nutrition and hydration by placing them at risk of health complications. Findings included: Record review of Resident #2 face sheet dated 09/21/23, documented a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that include cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), cognitive communication deficit (difficulty with thinking and communicating) , dysphagia oropharyngeal phase (swallowing problems occurring in the mouth and/or the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-06-28 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a safe, clean, and comfortable environment for 3 of 17 rooms (room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) reviewed for environment. The facility failed to repair deep scratches that exposed the sheetrock on the wall behind the head of the bed in room [ROOM NUMBER]. The facility failed to repair crater-like damage on the wall by the recliner in room [ROOM NUMBER]. The facility failed to repair multiple dark reddish stains were on the wall above the bed in room [ROOM NUMBER]. These failures could place the residents at risk for a diminished quality of life and a diminished clean well-kept environment. Findings included: 1. During an observation on 06/26/2023 at 8:03 AM, Resident #28 was in her bed, in room [ROOM NUMBER], an observation was made of deep scratches that exposed the sheetrock on the wall behind Resident #28's head of the bed. Resident #28 said she was unable to see the deep scratches because she was…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · E2023-06-28 · tag F0644 — pattern
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screenings for 3 of 9 residents (Residents #37, #11 and #28) reviewed for PASRR. The facility failed to ensure Residents #37, #11 and #28's PASRR Level 1 screening indicated a diagnosis of mental illness. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care and specialized services to meet their needs. Findings include: 1. Record review of Resident #37's face sheet, dated 06/28/2023, indicated Resident #37 was a [AGE] year-old female, admitted to the facility on [DATE] with a diagnoses which included Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), unspecified mood disorder, and auditory/visual hallucinations (perception of hearing and seeing something that was not actually there). Record review of Resident #37'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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-06-28 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 3 of 17 residents (Resident #21, Resident #39, ad Resident #28) reviewed for care plans. The facility failed to ensure Resident #21's care plan indicated he used oxygen. The facility failed to ensure Resident #39's care plan indicated the proper usage of her grab bar. The facility failed to care plan Resident #28's tracheostomy. These failures could place the residents at increased risk of not having their individual needs met and a decreased quality of life. Findings included: 1. Record review of Resident #21's face sheet, dated 06/27/2023, indicated Resident #21 was a [AGE] year-old male, originally admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus (blood sugar disorder), Parkinson's disease (nervous system disorder that impacts…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-06-28 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure: 1. Food items were dated and labeled. 2. Dented can good were removed from the shelve. 3. Sanitation bucket included the correct sanitation. 4. The ice machine was clean and free from debris. These failures could place residents at risk for cross contamination and foodborne illness. Findings included: During an observation of the kitchen freezer on 06/26/2023 starting at 8:09 a.m. revealed a half bag of chocolate chip cookies unlabeled and undated, and a half bag of French fries undated and unlabeled. During an observation and interview with the Dietary Manager of the kitchen walk in refrigerator on 06/26/2023 at 8:10 a.m. revealed a large plastic container with a brown liquid substance that was identified by the dietary manager as cooking grease unlabeled and undated. During an observation on 06/26/2023 at 8:12 a.m., Dietary Aide E placed a small…

    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 · 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 maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 5 of 7 meetings (June 2023, April 2023, March 2023, January 2023, and December 2022) reviewed for QAPI. The facility did not ensure the Infection Control Representative attended their QAPI meetings in June 2023, April 2023, and December 2022. The facility did not ensure the Medical Director attended their QAPI meetings in March 2023 and January 2023. This failure could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented, and no appropriate guidance developed. Findings included: Record review of the facility's Infection Control Representative Committee sign-in-sheets indicated the Infection Control Representative did not sign in for their meetings in June 2023, April 2023, and December 2022. The Medical Director did not sign in for their QAPI meetings in March 2023 and January 2023. During an interview on 6/28/23 at 8:15 AM, the Medical…

    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 · E2023-06-28 · tag F0925 — failed to control pests — pattern
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free from pests in 1 of 5 halls, 1 of 1 dining room, 1 of 1 kitchen, and 2 of 13 (Resident #23 and Resident #27) residents reviewed for pest control. The facility did not maintain an effective pest control program to ensure the facility was free of flies. This failure could place residents at risk for an unsanitary environment and a decreased quality of life. Findings included: 1. Record review of a face sheet dated 06/30/2023, indicated Resident #23 was an [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included hypertensive heart disease with heart failure (complications of high blood pressure that affect the heart), Alzheimer's disease (progressive disease that destroys memory and other important mental functions), and transient cerebral ischemic attack (temporary blockage of blood flow to the brain). Record review of the Quarterly MDS…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-28 · 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 interview, and record review the facility failed to ensure assessments accurately reflected the resident status for 1 of 17 residents (Resident #31) reviewed for MDS assessment accuracy. The facility failed to accurately reflect Resident #31's nutritional approaches on the quarterly MDS assessment. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of Resident #31's face sheet dated 06/27/23 indicated an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #31 had a diagnoses which included type 2 diabetes (the way the body processes blood sugar), hypertension (force of the blood against the artery walls is too high) and schizoaffective disorder (mood disorder). Record review of Resident #31's quarterly MDS dated [DATE] indicated Resident #31 had a BIMS score of 99 due to Resident #31 was unable to complete the interview. The quarterly MDS indicated Resident #31 made himself-understood and had 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-28 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal hand oral hygiene for 1 of 3 residents (Resident #34) reviewed for Activities of Daily Living. The facility did not provide scheduled showers for Resident #34. This failure could place residents at risk of not receiving services/care and a decreased quality of life. Findings Include: Record review of the consolidated physician order dated 6/28/2023 indicated, Resident #34 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included Nontraumatic subarachnoid hemorrhage (a blood vessel that burst into the brain), Aphasia, (loss of ability to understand or express speech), Age-related osteoporosis (weak or brittle bones), Pain in right arm, Hemiplegia (paralysis of one side of the body) affecting the right dominant side. Record review of the quarterly MDS…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-28 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    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 an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being for 1 of 17 residents (Resident #28) reviewed for activities. The facility failed to provide activities for Resident #28. The facility failed to ensure Resident #28 had activities care planned. These failures could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being. Findings included: Record review of a face sheet dated 06/28/2023 indicated, Resident #28 was a [AGE] year-old female, initially admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses which included acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia (a condition where there's not enough oxygen or too much carbon dioxide in your body), hypertensive heart…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-28 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 out of 2 residents (Resident #9) reviewed for pressure ulcers. LVN A failed to follow the physician orders when providing wound care to Resident #9. This failure could place residents at risk of complications which include worsening of existing wounds, development of new wounds, and infection. Findings included: Record review of a face sheet dated 06/28/2023, indicated Resident #9 was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus with hyperglycemia (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel with high blood sugars), paraplegia (paralysis of all or part of your trunk, legs, and pelvic organs),…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-28 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for 1 of 17 residents (Resident #35) reviewed for nutrition. The facility did not ensure dietary recommendations was implemented for Resident #35. This failure could place residents at risk for decreased nutritional status, decline in health, serious illness, or hospitalization. Findings included: Record review of Resident #35's face sheet, dated 06/28/2023, indicated Resident #35 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included end stage renal disease, essential hypertension (high blood pressure), and type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar). Record review of Resident #35's physician order summary report, dated 06/27/2023, indicated an active physician's order for active liquid protein (nutritional supplement), 30 ml by mouth two times a day for health with a start date…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-28 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel, and labeled and dated correctly for 1 of 4 medication carts (Hall A/B/room [ROOM NUMBER] nurse medication cart) reviewed for storage of medications. The facility failed to ensure Hall A/B/room [ROOM NUMBER] nurse medication cart was secured and unable to be accessed by unauthorized personnel. These failures could place residents at risk for not receiving drugs and biologicals as needed and a drug diversion. Findings included: During an observation and interview starting on 06/26/2023 at 2:17 PM, LVN A was in a resident room and the Hall A/B/room [ROOM NUMBER] nurse medication cart was in the hallway in front of the resident's room facing away from the entrance unlocked. LVN A came out of the resident's room and said, I must have forgot to lock it, I usually do. LVN A said the medication cart should be locked anytime she walked away from it, and it was out of…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-28 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    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 the meals served to residents met the nutritional needs of residents for 1 of 1 meal (the lunch meal), as evidenced by: The facility failed to ensure [NAME] D followed the recipe for pureeing the pork loin, green beans, and rice pilaf during the lunch meal. These failures could place residents at risk for weight loss, not having their nutritional needs met, and a decreased quality of life. Findings included: During an interview on 06/27/2023 beginning at 11:15 a.m., [NAME] D was preparing to puree the residents' meal. [NAME] D stated she knew the recipe and the proper procedures but did not have a recipe to follow. [NAME] D stated the recipes were not provided by the previous dietary manager. [NAME] D stated she guessed on how much food was needed for the 4 pureed residents. [NAME] D stated she eye-balled the consistency, she wanted the consistency to be thinner than a pudding but thicker than a nectar/shake. [NAME] D stated she used broth or milk to ensure the consistency was met. [NAME] D stated…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-28 · 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

    Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 5 staff (LVN A, CNA B, CNA C) reviewed for infection control. The facility failed to ensure CNA B and CNA C appropriately collected soiled linen after removing them from Resident #9's bed. The facility failed to ensure LVN A changed gloves and performed hand hygiene while providing wound care to Resident #9. These failures could place residents and staff at risk for cross-contamination and the spread of infection. Findings included: During an observation on 06/26/2023 starting at 2:41 PM, CNA B and CNA C walked out of Resident #9's room after providing incontinent care. Dirty sheets observed on the floor. LVN A entered the room to set up to provide wound care to Resident #9. LVN A walked around the dirty sheets and she entered and exited the room to gather all her wound care supplies. LVN 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.

    Infection Control 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

No federal fines in the current CMS record.

Part of a chain

This home belongs to TANABELL HEALTH SERVICES — 5 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 5 of 53.0+2.0 vs chain
Health inspection 5 of 52.8+2.2 vs chain
Staffing 3 of 52.2+0.8 vs chain
Quality measures 3 of 54.2-1.2 vs chain
The other 4 homes this chain runs (chain average 3.0★, 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 / managerTypeRoleShareSince
BELL, TODDIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF15%since 07/22/2025
TANABELL HEALTH SERVICES, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2025
BELL, TROYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2025
PILLETTE, CHEKEITHAIndividualADP OF THE SNFsince 10/01/2025

CMS files one row per role, so the 9 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$3.1M
Net patient revenuemost recent cost report
-38.8%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 90%Medicare 3%Other / private 7%

About 90% 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. 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

$286per resident / day
operating cost
$8,684per month
≈ monthly operating cost
$206per 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 675251. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-10-02, 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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