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Brentwood Place Two

3505 S Buckner Blvd Bldg 3, Dallas, TX 75227 · For profit - Corporation · 120 certified beds · (214) 388-0519 Medicare & Medicaid certified

Call the home — (214) 388-0519 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Feb 20242 immediate-jeopardy citations CMS recorded as corrected before the inspection ended (past non-compliance)$14,433 in federal fines
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Feb 2024
  • 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
  • inspectors recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $14,433 in federal fines (most recent 2024-02-29)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • 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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 5 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

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1 Medical Pkwy · (972) 243-5437 · Call to confirm hours
Pharmacy
10 Medical Pkwy Ste 107 · (888) 370-1724 · Call to confirm hours
Grocery
3046 Forest Ln · (972) 406-8555 · Call to confirm hours
Park
Mallon Park, 2840 Millwood Dr · Typically dawn to dusk
Place of worship
1404 W Hebron Pkwy · (469) 348-6657

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 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 rating3★
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 increased5.8%15.8%15.4%better
Long-stay residents who lose too much weight0.8%3.0%5.4%better
Long-stay residents with a catheter left in their bladder0.2%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.0%2.4%6.5%check this — see note marked star 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 injury0.8%3.3%3.3%better
Long-stay residents whose ability to walk worsened11.0%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication16.1%18.0%18.9%better
Long-stay residents given the seasonal flu vaccine98.1%98.0%95.3%typical
Long-stay residents with pressure ulcers4.2%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control15.6%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table20.1%9.6%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine71.4%88.0%79.4%worse

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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.

0.18U.S. median 0.31
Therapy hours / resident / day
0.06hours / resident / day
Physical therapy
0.07hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.18 therapist hours per resident per day in 2026Q1 — more than 17% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 13% 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
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 identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in 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 SNFs0.951.02Oct 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

0.46
RN hours/ resident / day
0.51
LPN hours/ resident / day
1.53
Aide hours/ resident / day
2.51
Total nurse hours/ resident / day
0.20
RN hoursweekends
39.4%
Total nursing turnover
45.5%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 101.3 residents a day — about 84% occupied, or roughly 19 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 2.51 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.53 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 2.14 hrs/resident/day on weekends vs 2.66 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.57 to 0.20 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

8
deficiencies at the latest standard inspection (2026-03-05)
7
at the previous standard inspection (2024-12-12)

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.

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.

32 citations, most serious first. The 12 most serious are shown; the remaining 20 are one tap away and print in full.

  • Immediate jeopardy · J2024-02-29 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to protect a resident's right to be free from neglect for 1 (Resident #1) of two residents reviewed for neglect. The facility failed to protect Resident #1 from neglect when they failed to conduct adequate therapeutic drug monitoring of Resident #1's lab levels who was receiving lithium. This led to Resident #1 being admitted to acute care hospital on [DATE] and was diagnosed with acute toxic encephalopathy secondary to lithium toxicity. Lab records revealed Resident #1's lithium level was 5.3 mmol/L (critical level) when he arrived at the hospital. The noncompliance was identified as PNC. The IJ began on 06/01/23 and ended on 10/02/23. The facility had corrected the noncompliance before the survey began on 02/27/24. This failure placed residents at risk for neglect and for serious adverse outcomes including drug toxicity, need for hospitalization, and/or death. Findings included: Record Review of Resident #1's Comprehensive MDS, dated [DATE], reflected…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Immediate jeopardy · J2024-02-29 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary 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 interview and record review, the facility failed to ensure each resident's drug regimen did not have an excessive dose, for an excessive duration, with inadequate monitoring for 1 of 2 residents (Resident #1) reviewed for unnecessary medications. The facility failed to conduct adequate therapeutic drug monitoring of Resident #1's lab levels who was receiving lithium. This led to Resident #1 being admitted to acute care hospital on [DATE] and was diagnosed with acute toxic encephalopathy secondary to lithium toxicity. Lab records revealed Resident #1's lithium level was 5.3 mmol/L (critical level) when he arrived at the hospital. The noncompliance was identified as PNC. The IJ began on 06/01/23 and ended on 10/02/23. The facility had corrected the noncompliance before the survey began on 02/27/24. This failure could place residents taking psychotropic medications at risk for serious adverse outcomes including drug toxicity, need for hospitalization, and/or death. Findings included: 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.

    Pharmacy Service Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2026-07-02 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for one (Resident #1) of five residents reviewed for pharmacy services.The facility failed to enter a physicians' order for Nitroglycerin 0.4mg sublingual tablet that was administered to Resident #1 on 06/19/2026. This failure could place residents at risk of not receiving medications as ordered by the physician and a delay in treatment and worsening of their condition.Findings included Review of Face Sheet dated 07/02/2026 reflected Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 was diagnosed with Type 2 Diabetes Mellitus (chronic metabolic disease where the body either resists insulin or doesn't produce enough of it, leading to high blood sugar), Peripheral Vascular Disease (slow, progressive circulation disorder characterized by narrowed,…

    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 before2026-03-05 · 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, record review and interview, the facility failed to ensure the resident had a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 3 of 10 residents restrooms (Resident Restroom [ROOM NUMBER], Resident Restroom [ROOM NUMBER], and Resident Restroom [ROOM NUMBER]) reviewed for hot water, 1 of 10 (Resident Restroom [ROOM NUMBER]) for restroom leaks and 1 of 8 residents (Resident #58) reviewed for bed linens. The facility failed to ensure residents had hot water in Resident Restroom [ROOM NUMBER], Resident Restroom [ROOM NUMBER], and Resident Restroom [ROOM NUMBER] on 3/3/26 and 3/4/26.The facility failed to ensure Resident Restroom [ROOM NUMBER] was free from leaks on 3/3/26 and 3/4/26. The facility failed to ensure Resident #58 was provided with clean and sanitary pillowcase on 3/3/2026. These failures could place residents at risk of exposure to infectious diseases, unsanitary environment 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-03-05 · tag F0807 — failed to offer suitable drinks — pattern
    Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
    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 drinks, including water and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration for 3 of 6 residents (Resident #29, Resident #15 and Resident #89) reviewed for hydration. The facility failed to ensure Residents#29 received a drink during lunch service on 3/3/26.The facility failed to ensure Resident #15 received a drink during lunch services on 3/3/26 and 3/4/26.The facility failed to provide Resident #89 drinking water on 3/3/26. These could place residents at risk of discomfort, dehydration, and/or a diminished quality of life. 1. Record review of Resident #29's face sheet, dated 3/5/26, revealed a [AGE] year-old male with an admission of 1/6/25. Resident #29 had the following active diagnoses: need for assistance with personal care, Thiamine Deficiency (condition that causes neurological and cardiovascular disease stemming from malnutrition or chronic alcohol use),…

    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 before2026-03-05 · 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 service safety for 1 of 1 kitchen reviewed for food safety for the facility's only kitchen.The facility failed to ensure the holding temperature was below 40 degrees F (Fahrenheit) for pureed potato salad served for lunch on 3/4/26.This failure could place residents at risk for food-borne illness, and food contamination.Findings included:During an observation and interview on 3/4/2026 11:46 a.m., of the lunch service revealed pureed potato salad was at 90 degrees F. (Pureed foods are smooth, lump-free food, made by blending or grinding cooked foods for those with chewing or swallowing difficulties).The Dietary Manager proceeded to scoop out the pureed potato salad to individual portions and prepared about 12-16 small cups, covered them and placed them in the freezer to cool them down further. The Dietary Manager stated the pureed potato salad should be at 41 degrees F and needed to cool down further before…

    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 · D2026-03-05 · tag F0687 — failed to care for feet properly — isolated
    Provide appropriate foot care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received proper treatment and care to maintain mobility and good foot health for 1 of 5 residents (Resident #66) reviewed for foot care. The facility failed to provide adequate foot care for Resident #66. This failure could place residents at risk for infection, impaired mobility, and poor foot health as well as a decline in their quality of life.Record review of Resident #66's face sheet, dated 3/5/26, reflected a [AGE] year-old male, admitted [DATE]. Resident #66 had the following active diagnoses: need for assistance with personal care, chronic pain, unsteadiness on feet, mood disorder, Generalized Anxiety Disorder ( a chronic mental health condition defined by excessive, uncontrollable, and persistent worry about daily events) and Major Depressive Disorder (a mental health condition characterized by persistent intense feelings of sadness, hopelessness and loss of interest in activities).Record review of Resident #66's…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-05 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide treatment and services to prevent complications of enteral feeding for one of two (Residents #92) residents reviewed for feeding tubes. The facility failed to ensure LVN G administered medications through Resident #92's G-Tube by gravity, and instead she pushed the water flushes and medication with the plunger and syringe on 03/03/26. This failure could place residents at risk of abdominal discomfort, nausea and tube rupture.Findings included: Record review of Resident #92's Quarterly MDS assessment, dated 12/25/25, reflected a [AGE] year-old female admitted to the facility on [DATE]. Staff assessed Resident #92 to be severely cognitively impaired. She received 51% or more of total calories through tube feeding. Diagnoses included traumatic brain injury (a disruption in brain function caused by a violent blow) and dysphasia (difficulty swallowing). Record review of Resident #92's Care Plan, dated 09/17/25, reflected, [Resident #92]…

    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 · D2026-03-05 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who needed respiratory care were provided with such care, consistent with professional standards of practice and the comprehensive person-centered care plan, for one of two (Resident #71) reviewed for quality of care. The facility failed to ensure the supplemental oxygen was provided at the physician ordered rate for Resident #71. This failure could place residents who received oxygen therapy at risk of oxygen toxicity. Findings included: Record review of Resident #71's quarterly MDS assessment, dated 01/05/26, reflected a [AGE] year-old female, admitted to the facility on [DATE] and readmitted [DATE]. She had a BIMS score of 4 which indicated she was severely cognitively impaired. Diagnoses included respiratory failure, pneumonia (serious lung infection), dementia, and dysphagia (difficulty swallowing). She was dependent on ADLs and required maximum assistance with transfers. The MDS assessment did not indicate she…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-05 · 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 ensure that drugs and biologicals used in the facility were secured and stored in accordance with current accepted professional principles for 1 of 3 medication carts (Nurse cart for Hall 200) observed for medication storage. The facility failed to ensure LVN G kept Resident #92's medications secured during medication administration on 03/03/26. This failure could place residents at risk of gaining access to unlocked medications that were not prescribed to them. Findings included: During an observation on 03/03/26 at 11:09 a.m. revealed LVN G was at the medication cart in front of Resident #92's room. LVN G poured two tablets of Tylenol 325 mg from the bottle and placed the tablets into a plastic sleeve and crushed them. LVN G poured the crushed pills into a plastic medication cup and added 10 cc of water to the cup. LVN G then filled a plastic cup with water. LVN G then put on gloves and a gown and entered Resident #92's room, leaving the medication on top of the medication cart out of the sight of LVN G.…

    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 · D2026-03-05 · tag F0808 — failed to follow doctor-ordered diets — isolated
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    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 therapeutic diets as prescribed by the attending physician for 1 (Resident #13) of 3 residents observed for therapeutic diets.The facility failed to provide Resident #13 with his regular diet minced and moist (MM5) texture as designated on his physician order on 3/4/2026.This failures could place residents at risk for poor intake, weight loss, unmet nutritional needs, and choking.Findings included:Record review of Resident #13's annual MDS Assessment, dated 01/03/2026, reflected Resident #13 was a [AGE] year-old male readmitted to the facility on [DATE]. His diagnoses included stroke (disruption in blood flow to the brain), hypertension (high blood pressure), malnutrition, and dysphagia (difficulty swallowing, indicating a disruption in moving food or liquid from the mouth to the stomach). He had BIMS of 0 indicating Resident #13 had severe cognitive impairment.Record review of Resident #13's Care plan, revised on 1/20/2026,…

    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 before2025-06-04 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    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 #1) of 6 residents reviewed for ADLs. The facility failed to ensure Staff provided consistent showers/baths for Resident #1. 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. Findings included: Record review of Resident #1's quarterly MDS assessment, dated 05/19/25, reflected a [AGE] year-old-male admitted to the facility on [DATE]. Resident #1's diagnoses included dementia, muscle weakness, and need for assistance with personal care. His BIMs score of 06/15 indicating sever cognition impairment. His functional status reflected extensive assistance with bathing. Record review of Resident #1's comprehensive plan of care dated 05/27/25 reflected, Focus: Resident#1 has…

    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
Show the remaining 20 citations
  • Potential for harm · Dcited before2025-06-04 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that a resident with urinary incontinence, based on the resident's comprehensive assessment, received the appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #1) of 6 residents reviewed for incontinent care. The facility failed to ensure Resident #1 was assisted with incontinence care and toileting in a timely manner on 06/04/2025. This failure could place residents at risk of skin breakdown, infection and a diminished quality of life by not receiving care and services to meet their toileting needs. Findings included: Record review of Resident #1's quarterly MDS assessment, dated 05/19/25, reflected a [AGE] year-old-male admitted to the facility on [DATE]. Resident #1's diagnoses included dementia, muscle weakness, and need for assistance with personal care. His BIMs score of 06/15 indicating sever cognition impairment. His functional status…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-04 · 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 control program designed to prevent the development and transmission of infection for one (Resident #1) of six resident observed for infection control. Facility failed to ensure CNA A performed hand hygiene and changed gloves while providing incontinence care to Resident # 1. Facility failed to ensure CNA A and LVN B performed hand hygiene before touching clean gloves. This failure could place the residents at risk for infection. Findings included: Record review of Resident #1's quarterly MDS assessment, dated 05/19/25, reflected a [AGE] year-old-male admitted to the facility on [DATE]. Resident #1's diagnoses included dementia, muscle weakness, and need for assistance with personal care. His BIMs score of 06/15 indicating severe cognition impairment. His functional status reflected extensive assistance for personal hygiene. He was frequently incontinent of bowel and bladder. 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-12-12 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to accommodate the needs and preferences of four of 10 residents (Resident #3, Resident #20, Resident #96, and Resident #19) reviewed for accommodation of needs. The facility failed to place Resident #3's call light within reach on 12/11/2024. The facility failed to place Resident #20's call light within reach on 12/11/2024. The facility failed to place Resident #96's call light within reach from 12/10/2024 until 12/11/2024. The facility failed to place Resident #19's call light within reach on 12/11/2024. This failure could place residents at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency. Findings included: Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed Resident #3 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of stroke, seizure disorder, unsteadiness on feet, and aphasia (language disorder that affects the ability to…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-12-12 · 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 observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for two (Hall 100 and Hall 600) of six halls observed for physical environment. The facility failed to ensure rooms and bathrooms toilets, and sinks were clean, safe, and in good repair in several rooms on Hall 100 and Hall 600. These failures could place residents at risk for diminished quality of life. Findings included: An observation on 12/12/2024 at 8:30 a.m. revealed in resident room [ROOM NUMBER]'s bathroom, the sink was hanging loosely on the wall. The base of the toilet was black with grim, and the caulking was missing surrounding the entire base of the toilet. The wall on the A side of the room had the paint missing, with black marks across the entire lower part of the wall. An observation on 12/12/2024 at 8:45 a.m., revealed in resident room [ROOM NUMBER]'s bathroom the door protector was loose on the top left corner of the door. Further…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-12-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure all assistive devices were maintained and free of hazards for six (Residents #22, #34, #48, #60, #67, and #89) of 6 residents reviewed for essential equipment. The facility failed to properly maintain wheelchairs for Residents #22, #34, #48, #67, and #89. The facility failed to properly maintain the overbed table for Resident #60. These failures could place residents at risk for equipment that is in unsafe operating condition, that could cause injury. Findings included: Review of Resident #22's quarterly MDS assessment, dated 10/08/2024, reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of unsteadiness on feet (unsafe standing), muscle wasting and atrophy (weakness), abnormalities of gait and mobility (unable to walk safely), and diabetes (high blood sugar). Further review of the MDS reflected the resident was cognitively severely impaired and unable to make decisions for themselves.…

    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 · Ecited before2024-12-12 · 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 observations, interviews, 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 seven of eight ( RN A, CNA D, CNA G, CNA H, CNA I, CNA J, and MA K) staff members and forty-four of 106 residents (Residents #79, #46, #2, #84, #8, #34, #4, #1, #31, #55, #6, #13, #65, #5, #87, #107, #4, #28, #7, #76, #10, #21, #106, #93, #16, #103, #104, #74, #27, #64, #29, #33, #72, #40, #54, #47, #81, #43, #63, #24, #58, #97, and #99) reviewed for infection control procedures. MA K failed to sanitize the blood pressure cuff before and after usage on Resident #63. RN A failed to disinfect her treatment scissors prior to starting a treatment on Resident #99's foot. CNA G failed to sanitize their hands after direct contact with residents #79, #46, #2, #84, #8, #34, #1, #31, #55, #6, #13, #65, and #5, while…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-12 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, including acute charting guidelines and high blood pressure necessary to care for resident's needs as identified through resident assessments and nursing documentation, for 1 (Resident #63) of 2 residents reviewed for quality of care. 1. MA K failed to communicate, and use the acute charting guidelines in the MAR, for charting of the increased blood pressure, and report to the charge nurse. By not reporting or domenting LVN B was unaware Resident #63 required a follow-up assessment, due to an increased blood pressure. These failures placed residents at risk for complications to include unnoticed change in condition and for residents not to receive needed nursing assessments. Findings included: Review of Resident #63's quarterly MDS dated [DATE] revealed the resident was a [AGE] year-old male admitted on [DATE]. Diagnoses to 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-12 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, and record reviews, the facility failed to obtain timely laboratory services to meet the needs of its residents for one (Resident #59) of five residents reviewed for laboratory services. The facility failed to collect labs for Resident #59 on 12/06/2024 as ordered by the physician. This failure could place residents at risk for a delay in ensuring treatment needs are identified and addressed. Findings included: Record review of Resident #59's annual MDS assessment dated [DATE] revealed Resident #59 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of stroke, diabetes, and heart failure. The MDS also revealed a BIMS score of 15 (suggested no cognitive impairment). Record review of Resident #59's care plan, updated on 12/10/2024, revealed Resident #59 was on antibiotic therapy for bone infection and urosepsis (urinary tract infection that has spread to the rest of the body). An intervention for this focus area was to report pertinent lab results to the…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-12 · tag F0812 — failed to store, cook, and serve food safely — isolated
    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 observations, interviews, 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 kitchen reviewed for food safety. 1. The facility failed to ensure dented cans were placed in a separate storage area. These failures could place residents at risk for food-borne illness and cross contamination. Findings included: Observation of the dry storage area on 12/10/2024 at 9:20am revealed the following: -1 46oz can of tomato juice was dented on the middle right. -1 66.5oz of light chunk tuna was dented on the top left. -1 6lbs diced tomatoes was dented on the top right. In an interview with the DM on 12/10/2024 at 9:30am she stated dented cans were stored in her office. She stated when dented cans were identified, the dented cans were returned to the vendor. She stated dented cans were provided weekly to the vendor. She stated the risks of dented cans not stored in a separate area was they could cause food poison and food borne illness if used. In an interview with [NAME] F…

    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 · E2024-10-18 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed ensure residents were free of any significant medication errors for one (Residents #1) of five residents reviewed for medications. 1. The facility failed to ensure LVN A held the Losartan Potassium 100 MG oral tablet when Resident #1's diastolic pressure and pulse was less than 60 on 10/05/24. 2. The facility failed to ensure RN B held the Losartan Potassium 100 MG oral tablet and Hydralazine HCl 50 MG oral tablet when Resident #1' diastolic pressure and pulse was less than 60 on 10/12/24. 3. The facility failed to ensure LVN C held the Hydralazine HCl 50 MG oral tablet when Resident #1's diastolic pressure and pulse was less than 60 on 10/05/24 and 10/06/24. 4. The facility failed to ensure RN D held the Hydralazine HCl 50 MG oral tablet when Resident #1's diastolic pressure and/or pulse was less than 60 on 10/04/24 and 10/08/24. These failures could place residents at risk of not receiving their medications as ordered or possible illness. Findings…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-29 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    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 food that was palatable for 3 (Resident #3, #4, #5) of 9 residents reviewed for food palatability. The facility failed to serve food that was palatable and nutritive. This failure could affect residents by placing them at risk of weight loss, altered nutritional status and diminished quality of life. Findings Included: Record Review of Resident #4 was a [AGE] year-old admitted to the facility 2 ½ years ago. Interview on 2/27/24 at 12:23 p.m. Resident #4, said the quality of the food is horrible and tasted bad. Record Review of Resident #5 was a [AGE] year-old admitted to the facility on [DATE]. Interview on 2/28/24 at 11:13 a.m. with Resident #5, laughed when asked how the food was at the facility. Resident said it was a joke and is not good at all. Interview on 2/28/24 at 4:40 p.m. with Resident #4, he had chicken noodle soup for lunch. He showed me a picture of breakfast that morning. The picture showed oatmeal in a Styrofoam 3…

    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 · D2024-02-29 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure all alleged violations involving abuse and neglect were reported immediately, but not later than 2 hours after the allegations were made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for one (Resident #1) of five residents reviewed for abuse and neglect. The facility failed to report allegation of neglect involving Resident #1 to the appropriate State Agency immediately on 04/21/23. This failure could place residents at risk of abuse and neglect. Findings Include: Record Review of Resident #1's Comprehensive MDS, dated [DATE], reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included anxiety disorder, depression, schizophrenia [a serious mental disorder in which people interpret reality abnormally], elevated blood pressure, and type…

    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 · Ecited before2023-11-02 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 2(Nurses Cart halls 100/200 and Med Aide cart halls 400/500) of 3 carts reviewed for pharmacy services. The facility failed to ensure: 1- LVN A, responsible for Nurses cart halls 100/200, counted controlled drugs every shift change and removed medications in unsecure containers from the Nurses Cart. 2- MA B responsible for Med Aide cart halls 400/500, counted controlled drugs every shift change. Thes failures could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication. Findings Included: 1- Record review and observation on 10/31/23 at 9:58 AM of Nurses Cart halls 100/200, with LVN A revealed: - missing signatures for Off duty and On duty for 10/04/2023, 10/10/2023, 10/22/2023 of the narcotic…

    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 before2023-11-02 · 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

    Based on observations, 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. 1. The facility failed to discard food stored in the refrigerator that should no longer be consumed. 2. The facility failed to discard food stored in the dry storage that should no longer be consumed. 3. The facility failed to ensure staff are only using clean utensils when accessing bulk foods. 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: Observation in facility's kitchen on 10/31/23 09:26 AM revealed cheese in refrigerator dated 10/30 with gray/ black spots on it that appears to be moldy and spoiled. Observation in facility's kitchen's dry storage on 10/31/2023 09:45 AM revealed two potatoes in the basket were rotten with multiple gnats on it. Observation in facility's kitchen's dry storage on 10/31/2023 09:58 AM revealed…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-02 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and stomach ulcers for 1 of 1 resident fed by gastrostomy tube (g-tube) (Resident #57), in that: The facility failed to ensure LVN C administered medication by gravity, he pushed them in via g-tube. This failure could result in residents aspirating (inhaling into airway) gastric contents and/or stomach ulcers in residents with a g-tube. The findings include: Review of Resident #57's Quarterly MDS assessment dated [DATE] reflected Resident #57 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included cerebrovascular accident (damage to the brain from interruption of its blood supply), dysphagia (A condition that affects the ability to produce and understand spoken language), 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-02 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 (100/200 hall Nurse Medication cart) of 3 medication carts reviewed for pharmacy services in that: The facility failed to ensure the 100/200 Hall Nurse Medication cart did not have an expired Assure Dose Control Solution. This failure could affect residents resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications. The findings include: Observation on [DATE] at 9:58 AM of hall 100/200 Nurse cart with LVN A revealed an expired blood glucose control solution (used to calibrate the glucometers). The blood glucose control solution opened and expired [DATE]. Interview on [DATE] at 10:01 AM, LVN A stated she had not seen the expired blood glucose control solutions and would have…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-22 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    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, functional, sanitary, and comfortable environment for two of eleven (Resident #1 and Resident #2) residents reviewed for environment. The facility failed to ensure that Resident #1's room had repaired windowsill and wall. The facility failed to ensure that Resident#2's room had repaired walls. This failure could place residents at risk for living in an unsafe, unsanitary, and uncomfortable environment. Findings included: Review of the face sheet for Resident #1 revealed a [AGE] year-old male admitted on [DATE] with an admitting diagnosis of insomnia, generalized muscle weakness, and high blood pressure. Review of the Quarterly MDS, dated [DATE], for Resident #1 revealed a BIMS score of 13 indicating resident was cognitively intact. MDS also revealed Resident #1 to need extensive assistance with bed mobility. Observation on 09/19/23 at 10:01 a.m., Resident #1's room revealed the left side of lower windowsill ledge detached…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-22 · 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 with or without an indwelling catheter, receives the appropriate care and services to prevent urinary tract infection to the extent possible for one (Resident#3) of six residents reviewed for incontinent care. The facility failed to ensure Resident #3 was assisted with incontinence care and toileting in a timely manner. This failure could place residents at risk of a diminished quality of life by not receiving care and services to meet their toileting needs. Findings included: Record review of Resident #3's Comprehensive MDS assessment, dated 08/08/23, reflected a [AGE] year-old-male admitted to the facility on [DATE]. Resident #3's diagnoses included dementia and need for assistance with personal care. His BIMs score was not assessed. His functional status reflected extensive assistance for personal hygiene. He was frequently incontinent of bowel and bladder. Record review of Resident #3's comprehensive plan of care…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-22 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that a resident with urinary incontinence, based on the resident's comprehensive assessment , received the appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #3) of 6 residents reviewed for incontinent care. The facility failed to ensure Resident #3 was assisted with incontinence care and toileting in a timely manner. This failure could place residents at risk of a diminished quality of life by not receiving care and services to meet their toileting needs. Findings included: Record review of Resident #3's Comprehensive MDS assessment, dated 08/08/23, reflected a [AGE] year-old-male admitted to the facility on [DATE]. Resident #3's diagnoses included dementia and need for assistance with personal care. His BIMs score was not assessed. His functional status reflected extensive assistance for personal hygiene. He was frequently incontinent of bowel…

    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 before2023-09-22 · 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 control program designed to prevent the development and transmission of infection for one (Resident #3) of six resident observed for infection control. Facility failed to ensure CNA B performed hand hygiene and changed gloves while providing incontinence care to Resident # 3. This failure could place the residents at risk for infection. Findings included: Record review of Resident #3's Comprehensive MDS assessment, dated 08/08/23, reflected a [AGE] year-old-male admitted to the facility on [DATE]. Resident #3's diagnoses included dementia and need for assistance with personal care. His BIMs score was not assessed. His functional status reflected extensive assistance for personal hygiene. He was frequently incontinent of bowel and bladder. Observation on 09/19/23 at 10:25 AM revealed CNA B assisted Resident #3 to toilet use and incontinent care. CNA B was observed completing hand hygiene before care and donned clean…

    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

$14,433 in federal fines across 1 penalty.

  • $14,433 — penalty dated 2024-02-29

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 →

RatingThis homeChain avg
Overall 3 of 52.3+0.7 vs chain
Health inspection 3 of 52.2+0.8 vs chain
Staffing 1 of 51.7-0.7 vs chain
Quality measures 5 of 54.3+0.7 vs chain
The other 65 homes this chain runs (chain average 2.3★, per CMS)
1 of 5Bluebird Wellness And RehabilitationSaint Louis, MO 1 of 5Brentwood Place ThreeDallas, TX 1 of 5Broadway Nursing & RehabilitationSan Antonio, TX 1 of 5Cameron Nursing CenterCameron, MO 1 of 5Carmel Hills Wellness & RehabilitationIndependence, MO 1 of 5Casa Arena Healthcare LLCAlamogordo, NM 1 of 5Casa Maria HealthcareRoswell, NM 1 of 5Forest Park Nursing & RehabilitationDallas, TX 1 of 5Fort Worth Wellness & RehabilitationFort Worth, TX 1 of 5Glenview Wellness & RehabilitationNorth Richland Hills, TX 1 of 5Highland Pines Nursing HomeLongview, TX 1 of 5Ivy Creek Wellness & RehabilitationWaco, TX 1 of 5Las Cruces Village Nursing & Rehabilitation LLCLas Cruces, NM 1 of 5Magnolia Wellness CenterSaint Louis, MO 1 of 5Maple Grove Wellness & RehabilitationFenton, MO 1 of 5Mineola Gardens Wellness & RehabilitationMineola, TX 1 of 5Pine Grove ManorSaint Louis, MO 1 of 5Rehab Of Kansas City SouthKansas City, MO 1 of 5The Hillcrest Of North DallasDallas, TX 1 of 5West Side Campus Of CareWhite Settlement, TX 1 of 5Willow Ridge Wellness & RehabilitationFort Worth, TX 1 of 5Willowcreek Wellness & RehabilitationFlorissant, MO 2 of 5Arbor Lake Nursing & Rehabilitation, LLCFort Worth, TX 2 of 5Aztec HealthcareAztec, NM 2 of 5Betty Dare Wellness & Rehabilitation LLCAlamogordo, NM 2 of 5Blue Springs Wellness & RehabilitationBlue Springs, MO 2 of 5Cypress Springs Wellness & RehabilitationMount Vernon, TX 2 of 5Fiesta Park Wellness & RehabilitationAlbuquerque, NM 2 of 5Hilltop At Blue River, TheKansas City, MO 2 of 5La Vida Buena HealthcareLas Vegas, NM 2 of 5Los Alamos Wellness & RehabilitationLos Alamos, NM 2 of 5McGregor Wellness & RehabilitationMc Gregor, TX 2 of 5Monarch Springs Wellness & RehabilitationUniversity City, MO 2 of 5Northrise Wellness & RehabilitationLas Cruces, NM 2 of 5Prescott Valley Nursing & RehabilitationPrescott Valley, AZ 2 of 5Prescott Village Nursing & RehabilitationPrescott, AZ 2 of 5Rehabilitation Center Of Independence, TheIndependence, MO 2 of 5San Antonio Wellness & RehabilitationSan Antonio, TX 2 of 5Skyline Nursing CenterDallas, TX 2 of 5Sunny Springs Nursing & RehabSulphur Springs, TX

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 / managerTypeRoleShareSince
CORYELL COUNTY MEMORIAL HOSPITAL AUTHORITYOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 12/01/2021
BYROM, DAVIDIndividualCORPORATE OFFICERsince 03/01/2015
BRENTWOOD 1-3 NURSING AND REHAB, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2021
GARETZ, DAVIDIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2021
GURWITZ, SOLOMONIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/02/2025
KAPLAN, ESTHERIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/02/2025
KAPLAN, MORDECHAIIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 08/14/2025
MINDLE, ADAMIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/02/2025
UNGER, JEFFREYIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/02/2025
3505 S BUCKNER BLVD, LLCOrganizationADP OF THE SNFsince 12/01/2021
CONTINUUM REHAB GROUP LLCOrganizationADP OF THE SNFsince 12/01/2021
ESDOV INVESTMENTS LLCOrganizationADP OF THE SNFsince 12/01/2021
MAGNOLIA REALTY, LLCOrganizationADP OF THE SNFsince 12/01/2021
OPCO CA SKILLED MGMT INC.OrganizationADP OF THE SNFsince 12/01/2021
OPCO TEXAS SKILLED MGMT LLCOrganizationADP OF THE SNFsince 12/01/2021
OREGON REALTY, LLCOrganizationADP OF THE SNFsince 12/01/2021
NAYAK, NEETAIndividualADP OF THE SNFsince 12/01/2003
ORAEKWE, VALENTINEIndividualADP OF THE SNFsince 06/10/2019

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.

$8.3M
Net patient revenuemost recent cost report
-5.9%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 78%Medicare 2%Other / private 20%

About 78% 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 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

$227per resident / day
operating cost
$6,911per month
≈ monthly operating cost
$215per day
avg. revenue, all payers

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

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 675702. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-05, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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