Brentwood Place Three
3505 S Buckner Blvd Bldg 4, Dallas, TX 75227 · For profit - Corporation · 120 certified beds · (214) 381-1815 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2025
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0565)
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,281 in federal fines (most recent 2026-02-06)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 2 to 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 8.1% | 15.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.9% | 3.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.5% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.6% | 2.4% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 0.8% | 3.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 8.9% | 14.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 12.0% | 18.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 99.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.6% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 15.4% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.7% | 9.6% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 1.1% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 96.9% | 88.0% | 79.4% | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.23 therapist hours per resident per day in 2026Q1 — more than 28% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 23% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not 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 SNF | not 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 discharge | not 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 discharge | not 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 discharge | not 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 identified | 95.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 5.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not 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 SNFs | 1.40 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 120 beds and averages 99.6 residents a day — about 83% occupied, or roughly 20 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.58 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.32 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.64 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.24 hrs/resident/day on weekends vs 2.71 on weekdays — 18% thinner on weekends. RN hours go from 0.32 to 0.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 39% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.
- Immediate jeopardy · Jcited before2026-02-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision for 1 of 5 residents (Resident #1) reviewed for elopement. The facility failed to ensure Resident #1 was adequately supervised when Resident #1 left the faciity on [DATE] and climbed through the fence and walked blocks away from the facility. Resident #1 contacted 911 and was transported to a nearby hospital. Resident #1 was located at a nearby hospital after the previous SW had called around to the closest hospital trying to find Resident #1. Staff did not know what time he left but were aware of his exit-seeking behavior and previous elopement attempt from the facility.An IJ was identified on 02/05/2026. The IJ template was provided to the ADM on 02/05/2026 at 11:29 A.M. While Resident #1 no longer resided at the facility, the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that was not immediate. The IJ…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-03 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure in accordance with applicable state and federal requirements: fire, 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 if the alleged violation involved abuse or neglect and resulted in bodily injury, to other officials (including the state Agency) and the administrator of the facility for 1 of 1 residents (Resident #1) reviewed for reporting abuse, in that: The Administrator (Abuse preventionist) and the DON failed to follow the facility's abuse policy by not reporting Resident #1's phone catching on fire while he was in his bed on 05/28/26 to HHS. This failure could place residents at risk for abuse and neglect.Findings included: Record review of Resident #1's face sheet, dated 06/03/26, reflected an [AGE] year-old male admitted to the facility on [DATE] with an initial admission date of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-03-19 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
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 provide the Resident Council group a private space for monthly resident council meetings for the facility's only resident council, for 18 of 18 confidential residents reviewed for resident rights. The facility failed to ensure resident council meetings were held in a private meeting space during their monthly scheduled March Resident Council meeting, when staff continued to enter the dining room while the resident council meeting was being held. This failure could place residents at risk of not being able to fully exercise their rights in the facility, which could lead to a lack of trust for staff working in their living environment, and emotional distress.Findings included: An observation of the Resident Council meeting, on 03/17/26 from 2:00 PM to 3:05 PM, revealed a group of eighteen residents were gathered to meet in the facility's dining room. During the meeting, several residents left (exact times unknown), leaving fourteen active participants in the meeting. The room was a large, open space, with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-03-19 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, 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 reviewed for food safety.1. The facility failed to ensure the stand-by freezer food items were dated and labeled.2. The facility failed to ensure the stand-by refrigerator food items were dated, labeled, and sealed.3. The facility failed to ensure that serving utensils were used when handling food items.These failures could place residents at risk for foodborne illness and foodborne intoxication.Findings included:During an observation on 03/17/2026 at 8:48 a.m. of the facility's only kitchen revealed:In the stand-by freezer:a package of food with the name covered, dated 4/11/26In the stand-by refrigerator:a used bag of shredded cheese, with no label or datea used bag of hard-boiled eggs, dated 03/16/26 with no use by date During an interview on 03/17/2026 at 8:59 a.m., the Dietary Manager revealed the frozen freezer item was minestrone soup and the date was supposed to read…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-19 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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
Based on observation, interview, and record review, the facility failed to respect and value resident's dignified existence for 1 of 6 halls (hall 300) reviewed for resident rights.The CNA failed to knock on residents' doors and introduce themself before entering the room for 4 of 10 rooms on 300 hall.This failure could please residents at risk for a negative psychosocial outcome and impact overall quality of life for residents.Findings included:During an observation on 03/18/2026 at 5:41 a.m. revealed CNA C and CNA D were doing rounds prior to shift change. CNA C was seen walking into 4 of 10 resident rooms on hall 300, without knocking or introducing herself.During an interview on 03/18/2026 at 5:44 a.m., CNA C revealed she was supposed to knock on residents' doors, say her name, and what she was there for before entering the residents' rooms. She said she had just provided ice to residents and was doing rounds one more time before leaving. CNA C indicated it was important to knock and greet residents before entering because residents need to be aware when staff were entering…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-19 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure each resident's right to personal privacy and confidentiality of personal records for 1 of 7 residents (Resident #1) reviewed for resident rights.The facility failed to protect Resident #1's confidential record by placing the resident's pharmacy receipt on top of a treatment cart which was sitting in hall 100 unattended. This failure could place residents at risk of their confidential information exposed to unauthorized personnel.Findings included:During an observation on 3/17/2026 at 8:45 a.m. revealed an unoccupied treatment cart in hall 100. On top of the treatment cart was Resident #1's pharmacy receipt for morphine. The receipt included Resident#1's name, date of birth , medication name (morphine), and the dosage of medication. During an interview on 3/17/2026 at 8:50 a.m., LVN A stated Resident #1 was discharged yesterday. He stated there should not be resident information in open areas because of HIPAA violation. He stated the residents had the right for their information to be kept…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision 1 of 1 (Resident #2) residents reviewed for microwave use.The facility failed to ensure Resident #2 was not alone in the staff conference room using the microwave to warm up his coffee. This failure could place residents at risk of burning themselves when trying to consume microwaved food and beverages.Findings included:Record review of Resident #2's face sheet, dated 03/18/2026, revealed a [AGE] year-old man admitted to the facility on [DATE] with a primary diagnosis of an infection following a (surgical) procedure.Record review of Resident #2's MDS, dated [DATE] revealed he had a BIMS of 15.Record review of Resident #2's care plan, dated 03/11/2026, revealed he was a risk for falls related to gait/balance problems (walking and balance problems) and had ADL self-care performance deficit related to post right knee arthroplasty (surgery to replace or repair knee). Interventions included…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-19 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to store drugs and biologicals in locked compartment for 1 of 4 carts reviewed for medication and biological storage.The facility failed to ensure a bottle of wound cleaner was not sitting on the side of an unoccupied cart in hall 100.This failure could place residents at risk of adverse reaction and injury. Findings included:During an observation on 3/17/2026 at 8:45 a.m., an unoccupied treatment cart in hall 100 was locked with a bottle of wound cleanser exposed on the side of the treatment cart. The wound cleanser bottle was half empty. There was residents present in hall 100 at the time of observation. During an interview on 3/17/2026 at 8:50 a.m., LVN A stated he was not sure who was using the treatment cart because the cart was shared amongst the nurses. He stated all drugs and biologicals should be stored inside a locked cart to prevent injuries or adverse reactions to residents if they got ahold of biologicals. During an interview on 3/17/2026 at 9:00 a.m., the treatment nurse stated the treatment cart…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-06 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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 ensure the physician was notified of changes for 1 of 5 residents (Resident #1) reviewed for elopement behaviors. The facility failed to inform the MD of Resident #1's elopement behaviors when requesting to discontinue his medical diagnosis of dementia.The failure could place residents at risk of not receiving the necessary care and treatment to meet their physical, mental, and psychosocial needs.Findings included: Record review of Resident #1's face sheet, dated 02/04/2026, reflected a [AGE] year-old male, admitted on [DATE] and discharged on 12/02/2025. Resident #1 diagnoses included cerebral infarction (blood clot forms in artery, disrupting blood flow to the brain, resulting in stroke) and osteoarthritis (protective cushion at ends of bones wear down, leading to stiffness and pain). Further record review of Resident #1's medical diagnoses revealed on 11/27/2025, the RNC had struck out the primary diagnosis dementia. The diagnosis did not appear on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-06 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure alleged violations of neglect were immediately reported to the State Agency within 24 hours for 1 of 5 (Resident #1) reviewed for elopement reporting. The facility failed to report Resident #1's subsequent and actual elopements from the facility on 11/02/2025 and 11/26/2025.This failure could place residents at risk of neglect and lack of oversight by the State Agency.Findings included:Record review of Resident #1's face sheet, dated 02/04/2026, reflected a [AGE] year-old male, admitted on [DATE] and discharged on 12/02/2025. Resident #1 diagnoses included cerebral infarction (blood clot forms in artery, disrupting blood flow to the brain, resulting in stroke) and osteoarthritis (protective cushion at ends of bones wear down, leading to stiffness and pain). Further record review of Resident #1's medical diagnoses revealed on 11/27/2025, the RNC had struck out the primary diagnosis dementia. The diagnosis did not appear on the face sheet. Record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-06 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives to meet the resident's medical, nursing, mental and psychosocial needs for 1 of 5 residents (Resident #1) reviewed for care plans. The facility failed to develop and implement the care plan for Resident #1's risk of elopement since his initial elopement attempt on 10/24/2025 and subsequent elopement attempt and actual elopement on 11/02/2025 and 11/26/2025.The facility failed to revise the care plan for Resident #1 to reflect his medical diagnosis of dementia.This failure could place residents at risk for not receiving proper care and services. Findings included: Record review of Resident #1's face sheet, dated 02/04/2026, reflected a [AGE] year-old male, admitted on [DATE] and discharged on 12/02/2025. Resident #1 diagnoses included cerebral infarction (blood clot forms in artery, disrupting blood flow…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · D2026-02-06 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medical records were complete, accurately documented, readily accessible, and systematically organized for 1 of 5 residents (Resident #1) reviewed for medical record accuracy. The facility failed to ensure there was not a discrepancy in Resident #1's dementia diagnosis that was discontinued, while his records (care plan, orders, psychiatric visits, and MAR) indicated Resident #1 was actively treatment for dementia.The facility failed to document the verbal conversation with Resident #1's MD regarding the discontinuation of dementia diagnosis.The facility failed to accurately and consistently complete Resident #1's Elopement Risk Evaluations when evaluating Resident #1's risk of elopement. This failure could place residents at risk of receiving treatment and care for inactive diagnoses and not receiving treatment and care when necessary to meet clinical, functional, mental, and psychosocial needs. Findings included:Record review of Resident #1's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-02 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to, in accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access for four (Resident #1) of ten residents reviewed for medication storage. The facility failed to ensure there was no nasal spray inside Resident #1's room on 10/21/2025. This failure could place residents at risk of misuse of medications that could lead to overdosing or underdosing.Findings included: Record review of Resident #1's Face Sheet, dated 10/21/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with failure to thrive (significant decline in physical and emotional well-being), depression (persistent feeling of sadness or loss of interest), anxiety (intense or excessive fear or worry), and malignant ascites (accumulation of fluid in the belly due to cancer). Record review of Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-11 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 #1) of 6 residents reviewed for ADL's. The facility failed to ensure Resident #1 had his fingernails trimmed and cleaned.These failures 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. Record review of Resident #1's annual MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of lack of coordination, unsteadiness on feet, muscle weakness, and hypertension (elevated blood pressure). He had a BIMS of 10 indicating his cognition was moderately impaired. He required partial/moderate assistance with personal hygiene. Record review of Resident #1's Comprehensive Care Plan last revised 08/31/25 reflected the following.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-08 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of three (CNA A) staff members and eight of eight residents (Resident #81, #30, #10, #50, #62, #52, #91 and #73) reviewed for infection control procedures. CNA A failed to perform hand hygiene after direct contact with residents #81, #30, #10, #50, #62, #52, #91, and #73 while serving meals on Hall 600. This failure could place residents at risk for healthcare associated cross contamination and infections. Findings included: Record review of Resident #81's 5-day [other payment] MDS assessment, dated 10/03/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #81 had diagnoses which included: schizoaffective disorder (mental illness), and depressive disorder (mental illness).…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-08 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the right to be free from abuse for one (Resident #36) of seven residents reviewed for abuse. The facility failed to ensure Resident #36 was free from abuse. On 3/07/2024 Hospitality Aide B called Resident #36 trash and used profanity when speaking to Resident #36. The noncompliance was identified as past noncompliance (PNC). The noncompliance began on 3/07/2024 and ended on 3/12/2024. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk for abuse and psychological harm. Findings included: Record review of Resident #36's Quarterly MDS dated [DATE] revealed Resident #36 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of anxiety, depression, and schizophrenia (a mental disorder). The MDS also revealed a BIMS score of 15 (suggested no cognitive impairment) and Section E of the MDS revealed no behavioral symptoms were present. Record review of Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-12 · tag F0641 — isolatedEnsure 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 interviews and record review, the facility failed to ensure assessments accurately reflected the resident's status for 2 of 4 residents (Resident #1 and Resident #3) reviewed for accuracy of assessments. 1. Resident #1's discharge MDS assessment dated [DATE] did not address his BIMS (Section C), his Mood (Section D), Behaviors (Section E), The MDS did not address the resident's Pain (Section J) to accurately reflect his current MD order for pain management. 2. Resident #1's quarterly MDS assessment dated [DATE] did not address Mood (Section D), Behaviors (Section E), The MDS did not address the resident's Pain (Section J) to accurately reflect his current MD order for pain management. 3. Resident #3's admissions MDS assessment dated [DATE] did not address Section I medical diagnosis of anxiety and depression, Section N did not address active diagnosis for depression and anxiety. Section O special treatments did not address her Central PICC line catheter, while a resident and at discharge. 4. Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-03-12 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, and record reviews, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for two (300 and 600 hall shower rooms) of three shower rooms reviewed for environmental conditions. The facility failed to ensure the shower rooms on the 300 hall and 600 hall were free of a black substance in between the tiles. This failure could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment. The findings included: Observations on 03/12/24 from 3:10 p.m. to 3:20 p.m., of the shower rooms on the 300 and 600 halls revealed the following: - The 300-hall shower room had a black substance, about 6 inches in length, on the left wall of the shower in between the grout where the wall tile and floor tile met. - The 300-hall shower room had a black substance, about 15 inches in length, on the back wall of the shower in between the grout of the tiles. - The shower room on the 600-hall had a black substance, about 4 inches in length, on the back wall of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-12 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 nutrition, grooming and personal and oral hygiene for one (Resident #1) of six residents reviewed for ADLs. The facility failed to ensure Resident #1 was provided incontinent care in a timely manner, resulting in the resident smearing fecal matter on his mattress, bed linens, window ledge and throwing the fecal matter on the floor of his bedroom. This failure could place residents at risk for discomfort, infection, and dignity issues. The findings included: Record review of Resident #1's face sheet, printed on 03/12/24, reflected Resident #1 admitted to the facility on [DATE]. Resident #1 had diagnoses of dementia (the loss of cognitive functioning), lack of coordination, apraxia following cerebral infarction (cognitive disorder that can occur after stroke), lack of coordination, obesity, hyperlipidemia (in excess of lipids…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-11-16 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure all patient care equipment was in safe, clean, comfortable environment and maintainance services for six (Residents #52, #85, #38, #11, #16 and #27) of 18 residents reviewed for essential equipment. The facility failed to properly maintain wheelchairs for Residents #52, #85, #38, #11, #16, and #27. These failures could place residents at risk for equipment that is in unsafe operating condition. Findings included: Review of Resident #52's quarterly MDS assessment, dated 11/04/23, reflected he was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses of CVA (Stroke) and limited range of motion lower limbs. Review of the Resident #52's plan of care dated 11/04/23 with updates reflected goals and approaches to include wheelchair mobility. Observation and interview on 11/13/23 at 10:00 a.m. revealed Resident #52 was sitting in his wheelchair with no skin problems, the wheelchair's left armrest was cracked, and foam was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-11-16 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. 1. The facility failed to ensure the ice machine filter and vent were free from dirt and dust and disrepair. 2. The facility failed to ensure the ice machine chute guard and outer surface was clean. 3. The facility failed to ensure food items in the refrigerator (1 of 3), freezer (2) and dry storage room were labeled and stored in accordance with the professional standards for food service. 3. The facility failed to discard items stored in refrigerator, freezers and dry storage that were not properly labeled or past the 'best buy', consume by or expiration dates. 4. The facility failed to separate dented/compromised canned goods from the non-dented canned good. 5. The facility failed to ensure dietary staff washed their hands or changed gloves when they touched other surfaces while handling food or upon entering or re-entering the kitchen. 6. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-11-16 · tag F0925 — failed to control pests — patternMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for four (Halls 200, 400, 500, 600, nurse's station, lobby, conference room and the main dining rooms), of six halls reviewed for pest control program. The facility had live common house flies and gnats in areas of the facility including the lobby, nurses station, halls 200, 400, 500 and 600 , conference room and the dining room. This failure could place residents at risk for spread of infection, cross-contamination, and decreased quality of life. Findings Include: Observation and interview 11/13/23 at 9:30 a.m., revealed 1-5 live house flies crawling on the bed covers of Resident #52 on Hall 200 There was a fly strip hanging on the resident's wall beside the window, with three dead flies and 15 dead gnats. Resident #52 stated that the fly strip was there because he was tired of the flies and the gnats flying around in his room, so he bought the fly strip. Resident #52 was asked if he had reported the flies and gnats to anyone,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-16 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to review and revise the person-centered comprehensive care plan to reflect the resident's current status, for 2 of 5 residents (Resident #55 and Resident #88) reviewed for care plans. The facility did not update Resident #55's care plan to reflect specific instructions for hospitalization and antibiotics. The facility did not update Resident #88's care plan to reflect specific instructions for smoking. These failure could place residents at risk for not receiving appropriate care and interventions to meet their current needs. The findings were: 1. Review of Resident #55's MDS quarterly assessment dated [DATE], reflected he was a [AGE] year-old male admitted on [DATE]. His diagnoses included Schizophrenia (mental illness), sepsis (infection), and depression. His BIMs score of 1 reflected his cognitive status was severely impaired and he required moderate to maximum assist of one staff member for activities of daily living. Record review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-16 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, and record review the facility failed to ensure all drugs and biological were secure in locked compartments and permitted only to authorized personal and inaccessible to unauthorized staff and residents for (one medication cart for Hall 500) of six medication carts reviewed for medication storage. The facility failed to ensure medication supplies were all stored in locked compartments and permit only authorized personnel to have keys, when RN B's and LVN C's one medication cart for Hall 500 was left unlocked and unattended by RN B and LVN C. This failure could result in resident access and ingestion of medications leading to a risk for harm and possible drug diversion. Findings included: An observation on 11/14/23 at 5:15 a.m. revealed an unidentified medication cart unlocked sitting at the entrance to Hall 500. The lock on the medication cart was popped out showing the red bottom indicating the cart was unlocked. An observation on 11/14/23 at 5:30 a.m. revealed the unidentified medication cart remained unlocked at the entrance to Hall 500. The lock…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$8,281 in federal fines across 1 penalty.
- $8,281 — penalty dated 2026-02-06
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 OPCO SKILLED MANAGEMENT — 66 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.3 | -1.3 vs chain |
| Health inspection | 2 of 5 | 2.2 | -0.2 vs chain |
| Staffing | 1 of 5 | 1.7 | -0.7 vs chain |
| Quality measures | 4 of 5 | 4.3 | -0.3 vs chain |
The other 65 homes this chain runs (chain average 2.3★, per CMS)
Showing 40 of 65; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| CORYELL COUNTY MEMORIAL HOSPITAL AUTHORITY | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 12/01/2021 |
| BYROM, DAVID | Individual | CORPORATE OFFICER | — | since 03/01/2015 |
| BRENTWOOD 1-3 NURSING AND REHAB, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| GARETZ, DAVID | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| MIRZA, MUHAMMAD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2026 |
| SILVA, PHILLIP | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/01/2015 |
| GURWITZ, SOLOMON | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 07/02/2025 |
| KAPLAN, ESTHER | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 07/02/2025 |
| KAPLAN, MORDECHAI | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 08/14/2025 |
| MINDLE, ADAM | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 07/02/2025 |
| UNGER, JEFFREY | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 07/02/2025 |
| 3505 S BUCKNER BLVD, LLC | Organization | ADP OF THE SNF | — | since 12/01/2021 |
| CONTINUUM REHAB GROUP LLC | Organization | ADP OF THE SNF | — | since 12/01/2021 |
| ESDOV INVESTMENTS LLC | Organization | ADP OF THE SNF | — | since 12/01/2021 |
| MAGNOLIA REALTY, LLC | Organization | ADP OF THE SNF | — | since 12/01/2021 |
| OPCO CA SKILLED MGMT INC. | Organization | ADP OF THE SNF | — | since 12/01/2021 |
| OPCO TEXAS SKILLED MGMT LLC | Organization | ADP OF THE SNF | — | since 12/01/2021 |
| OREGON REALTY, LLC | Organization | ADP OF THE SNF | — | since 12/01/2021 |
CMS files one row per role, so the 20 rows in the source record cover these 18 parties — each is shown once here with every role it holds. Nothing is omitted.
9 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 81% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in TX
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 675352. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-19, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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