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Skyline Nursing Center

3326 Burgoyne St, Dallas, TX 75233 · Government - Hospital district · 204 certified beds · (214) 330-9291 Medicare & Medicaid certified

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Flagged for abuse5 immediate-jeopardy citations
Insights

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

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • CMS has flagged it for abuse
  • it has abuse, neglect, or exploitation citations (F0600, F0602, F0607) — most recent Jan 2026
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 5 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (39) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing rating is low (1/5)

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

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

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 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 4 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
3434 W Illinois Ave Ste 202 · (214) 888-9000 · Call to confirm hours
Pharmacy
Oportun0.6 mi
3420 W Illinois Ave · (214) 273-4450 · Call to confirm hours
Grocery
3045 W Pentagon Pkwy · (214) 524-9968 · Call to confirm hours
Park
3443 W Kiest Blvd · (214) 670-4100 · Typically dawn to dusk
Place of worship
2929 S Westmoreland Rd · (214) 330-8700

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
Short-stay residentsrehab / post-hospital 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 1 stars. From monthly CMS archive snapshots.

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

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased9.6%15.8%15.4%better
Long-stay residents who lose too much weight0.7%3.0%5.4%better
Long-stay residents with a catheter left in their bladder0.1%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.3%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 injury1.1%3.3%3.3%better
Long-stay residents whose ability to walk worsened6.6%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication16.7%18.0%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers2.1%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control13.9%13.4%21.2%better
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine94.8%88.0%79.4%better
Short-stay residents rehospitalized after admission28.0%25.7%22.6%worse
Short-stay residents with an outpatient ER visit3.6%12.3%12.0%better
Long-stay hospitalizations per 1,000 resident days2.162.171.67worse
Long-stay outpatient ER visits per 1,000 resident days1.532.061.80better

* 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.

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.

39.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 32 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

39.9%U.S. median 51.5%
Got home and stayed home
10.6%U.S. median 10.7%
Went back to hospital
65.2%U.S. median 56.6%
Met the expected recovery
0.34U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.18hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 65.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 23 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.34 therapist hours per resident per day in 2026Q1 — more than 58% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 50% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF39.9%CMS range 25.2–54.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.6%CMS range 8.1–15.510.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge65.2%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge52.2%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge39.1%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified57.5%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.161.02Oct 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

0.44
RN hours/ resident / day
0.60
LPN hours/ resident / day
2.01
Aide hours/ resident / day
3.05
Total nurse hours/ resident / day
0.46
RN hoursweekends
50.0%
Total nursing turnover
43.8%
RN turnover

How full it usually is: this home is certified for 204 beds and averages 169.6 residents a day — about 83% occupied, or roughly 34 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 3.05 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.44 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.01 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 2.74 hrs/resident/day on weekends vs 3.18 on weekdays — 14% thinner on weekends. RN hours go from 0.43 to 0.46 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 50% 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 (2026-04-14)
6
at the previous standard inspection (2025-01-29)

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.

39 citations, most serious first. The 15 most serious are shown; the remaining 24 are one tap away and print in full.

  • Immediate jeopardy · Kcited before2023-09-27 · tag F0580 — failed to tell family and doctor about changes — pattern
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to consult the resident's physician and resident representative when there was a significant change in the resident's physical, mental or psychosocial status for one (Resident #1) of five residents reviewed for resident rights. 1. The facility failed to ensure Resident #1's physician and psychiatrist was notified when she refused her prescribed psychotropic and blood pressure medications consistently for over a week from 09/01/23 through 09/09/23 . 2. The facility failed to ensure Resident #1's RP/family member(s) were notified when she refused her prescribed psychotropic and blood pressure medications consistently for over a week from 09/01/23 through 09/09/23. An Immediate Jeopardy was identified on 09/14/23. The IJ Template was provided to the facility on [DATE] at 1:45 PM. While the Immediate Jeopardy was removed on 09/18/23, the facility remained out of compliance at the severity level of No actual harm with potential for more than minimal harm that…

    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
  • Immediate jeopardy · K2023-09-27 · tag F0600 — failed to protect residents from abuse and neglect — pattern
    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 observations, interviews, and record reviews, the facility failed to ensure the resident has the right to be free from neglect for one (Resident #1) of five residents reviewed for neglect. 1. The facility failed to provide prescribed psychotropic medications to Resident #1, who lived with dementia and mental illness, and moved her to several different rooms in a week's time which resulted in her having increased behaviors resulting in two separate unwitnessed resident to resident altercations. 2. The facility failed to notify the MD when Resident #1 refused her psychotropic medications prior to the two resident to resident altercations. An Immediate Jeopardy was identified on 09/14/23. The IJ Template was provided to the facility on [DATE] at 1:45 PM. While the Immediate Jeopardy was removed on 09/18/23, the facility remained out of compliance at the severity level of Actual harm that is not Immediate Jeopardy and at a scope of pattern due to the facility's need to implement and monitor 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · K2023-09-27 · tag F0607 — failed to have anti-abuse policies — pattern
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to develop and implement written policies and procedures that prohibit and prevent neglect for one (Resident #1) of five residents reviewed for neglect policies. The facility failed to provide prescribed psychotropic medications to Resident #1, who lived with dementia and mental illness, and moved her to several different rooms in a week's time which resulted in her having increased behaviors resulting in two separate unwitnessed resident to resident altercations. The facility failed to notify the MD when Resident #1 refused her psychotropic medications prior to the two resident to resident altercations. The facility did not provide Resident #1 with behavioral interventions and instead, initiated an unplanned and inappropriate transfer that led to Resident #1 being left across the street from the facility and subsequently arrested and incarcerated for a week. The facility was unaware Resident #1 had been arrested for two days and did not…

    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
  • Immediate jeopardy · K2023-09-27 · tag F0742 — pattern
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
    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 displayed or is diagnosed with a mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for two (Residents #1 and #4) of five residents reviewed for psychosocial concerns. 1) The facility management and staff did not observe and intervene for manifestations related to mental and psychosocial adjustment difficulties when Resident #1, who lived with dementia with behavioral disturbance and mental illness was changed to three different rooms in a week, after she had been living in a room alone for most of 2023. When Resident #1 was moved to a new hall/floor, she slapped a male resident who lived across the hall from her on 09/05/23 and then moved to a different room on a new hall/floor and placed with an…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · J2023-09-27 · tag F0624 — isolated
    Prepare residents for a safe transfer or discharge from the nursing home.
    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 and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for one (Resident #1) of three residents reviewed for transfer and discharge rights. The facility failed to provide or document sufficient preparation for an orderly transfer when Resident #1 allegedly got into an unwitnessed physical altercation with her new roommate. An Immediate Jeopardy was identified on 09/14/23. The IJ Template was provided to the facility on [DATE] at 1:45 PM. While the Immediate Jeopardy was removed on 09/18/23, the facility remained out of compliance at the severity level of Actual harm that is not Immediate Jeopardy and at a scope of pattern due to the facility's need to implement and monitor the effectiveness of its corrective systems. This failure could place residents at risk of a disruption in their care and services and denying them and their RP a voice regarding their…

    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 · E2026-04-14 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents had a right to a dignified existence and self-determination that promoted enhancement of his or her quality of life, recognizing each resident's individuality for 4 (Residents #14, #21, #178 and #184) of 6 residents reviewed for resident rights. The facility failed to ensure Resident #178's Care Plan was followed. Resident #178's mattress was placed directly on the floor which could be seen by anyone who entered the men's behavioral unit due to the location of Resident #178's room.The facility failed to ensure residents' information was not loudly discussed in the dining room and/or down the hallway for anyone to hear as evidenced by the following: -CNA Q loudly stating it was embarrassing that Resident #21 urinated in his pants in the dining room.-CNA K loudly reporting Resident #178 did not want to eat anymore.-CNA Q loudly telling coworkers she was going to change Resident #184.-ADON M loudly telling CNA K that Resident…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-04-14 · 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

    Based on observation, record review and interviews, 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 4 of 18 resident beds (Resident bed #1, Resident bed #2, Resident bed #3, Resident bed #4) reviewed for bed linens. 1. The facility failed to ensure residents had linen that was clean and in good repair on Resident bed #1, Resident bed #2, Resident bed #3, and Resident bed #4 on 4/12/26 and 4/13/26.3. The facility failed to maintain enough linen on the downstairs secured unit. These failures could place residents at risk of exposure to infectious diseases, unsanitary environment and a decline in quality of life. Findings include: An observation of the downstairs secured unit on 04/12/2026 at 1:00 PM revealed Resident bed #1 and Resident bed #2 had soiled and worn linen, Resident bed #3 had soiled linen, and Resident bed #4 had soiled linen. In an interview on 04/13/2026 at 2:11 PM with LVN F, stated she was the charge nurse and 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-04-14 · 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 ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 4 of 12 residents (Resident#10, Resident#15, Resident#50,and Resident #169) reviewed for ADL care.The facility failed to provide Resident #169 assistance with timely incontinence care for at least 4 hours.The facility failed to ensure Resident #10 had his fingernails cleaned and trimmed on 04/12/26.The facility failed to ensure Resident #15 had his face cleaned and his eye free of buildup on 04/13/26.The facility failed to ensure Resident #50 had her fingernails cleaned and trimmed on 04/12/2026. These failures could place residents at risk for loss of dignity, risk for infections and a decreased quality of life. Findings included: 1.Record review of Resident #169's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses…

    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 · E2026-04-14 · tag F0809 — failed to serve meals on a reasonable schedule — pattern
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that each resident received, and the facility provided at least three meals daily, at regular times comparable to normal mealtimes in the community for two (lunch on 04/12/26 and 04/13/26) of two meals observed for dietary services. The facility failed to serve the 04/12/26 and 04/13/26 lunch meals on time at the scheduled time based on the meal postings. This failure could place residents at risk for decreased meal satisfaction, decreased intake, loss of appetite, side effects from medications given without food, and diminished quality of life. Findings included: Review of Resident #174's admission MDS assessment dated [DATE] reflected Resident #174 had a BIMS of 14 indicating he was cognitively intact. Review of Resident #37's Quarterly MDS assessment dated [DATE] reflected Resident #37 had a BIMS of 14 indicating he was cognitively intact. Review of Resident #38's quarterly MDS assessment dated [DATE] reflected Resident #38…

    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 before2026-04-14 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 5 residents (Resident #164, # 21, 157, 184, and #105) of 10 residents observed for infection control. The facility failed to ensure:CNA B changed gloves and completed hand hygiene during incontinent care for Resident #164 on 4/12/26.CNA K did not utilize her bare hands when assisting Residents #21, #157 and #184 during lunch on 04/12/2026.CNA N wore appropriate PPE and completed hand hygiene during incontinent care for Resident #105, who was on Enhanced Barrier Precaution, on 4/13/26. These failures could place residents at risk for infection and cross contamination of pathogens and illness. Resident #164 Record review of Resident #164's Quarterly MDS assessment dated [DATE] reflected Resident #164 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia (decline in mental ability such as…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-14 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the responsible party regarding changes in condition for 1 (Resident #178) of 6 sampled residents reviewed for changes in condition and resident rights. The facility failed to notify Resident #178's responsible party when he had a fall and when he had a newly acquired pressure wound. This failure could place residents at risk of not having their responsible party notified of changes resulting in a delay in medical intervention.Review of Resident #178's admission Record dated 04/14/2026 revealed Resident #178 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #178 was diagnosed with Paranoid Schizophrenia (chronic mental health disorder characterized by intense, irrational delusions and auditory hallucinations), Senile Degeneration of Brain (progressive mental decline and brain atrophy associated with advanced age, characterized by memory loss, confusion, and reduced cognitive function), Schizoaffective Disorder…

    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 · D2026-04-14 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 had the right to personal privacy for personal care for one of five (Resident #105) residents observed for personal care. CNA N failed to provide privacy during incontinent care of Resident #105 on 04/13/26. The failure could affect residents, by placing them at risk for loss of privacy and dignity. The findings were: Record review of Resident #105's annual MDS assessment, dated 02/17/26, reflected an [AGE] year-old male who was admitted to the facility on [DATE], and readmitted on [DATE]. Resident #105 had diagnoses which included hypertension (high blood pressure), type 2 diabetes mellitus (high blood sugar), Cerebrovascular Accident (a medical emergency occurring when blood flow to the brain is interrupted (ischemic) or a vessel bursts (hemorrhagic), causing rapid brain cell death) ,non-Alzheimer's dementia (diseases that affect memory, thinking, and the ability to perform daily activities), and Hemiplegia or…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-14 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to assist residents in obtaining routine dental care for one of 8 residents (Resident #117) reviewed for dental services. The facility failed to ensure Resident #117 received routine dental services since admission on [DATE]. This failure could place residents at risk of difficulty with eating, decline in eating and a delay in treatment for dental services.Findings included Record review of Resident #117's face sheet undated reflected Resident #117 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (conditions characterized by paralysis or weakness on the right side of the body due to a stroke), dysphagia (difficulty swallowing), cognitive communication deficit and vascular dementia ( significant symptoms of dementia that affect daily living). Record review of Resident #117's quarterly MDS assessment 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-08 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free from misappropriation of property for one (Resident #1) of 10 residents reviewed for misappropriation of property. The facility failed to protect Resident #1 from misappropriation of property by one of their employees, Housekeeper A. On 12/18/2025 the Social Worker came to know that Housekeeper A used Resident #1's bank account for unauthorized transactions. As a result, Resident #1 lost approximately $300.00 from his personal bank account. This failure could place residents at risk of loss of lifelong earnings. Findings included: Record review of Resident #1's face sheet dated 01/08/2026 revealed Resident #1 was a [AGE] year-old male, with an original admission date of 07/15/2025. Diagnoses included: Radiculopathy lumbosacral region (pain in the lower back), paroxysmal atrial fibrillation (irregular heartbeat), cerebrovascular disease (blood flow to the brain affected), adult failure to thrive (overall decline…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-06 · 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 observations, interviews, and record review the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 residents (Resident#1 and #Resident #2) of 6 residents reviewed for ADLs. The facility failed to ensure: 1. Resident #1 had his fingernails cleaned and trimmed on 08/06/25.2. Resident #2 had her fingernails cleaned and trimmed on 08/06/25.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.1. Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included hypertension (elevated blood pressure), cerebrovascular accident (Occurs when blood flow to the brain is interrupted, leading to brain cell death and potential neurological damage)…

    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 24 citations
  • Potential for harm · Dcited before2025-08-06 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #3) reviewed for infection control. The facility failed to ensure CNA A performed hand hygiene while providing incontinence care to Resident #3 on 08/06/25. These failures could place residents at risk of cross-contamination and development of infections. Record review of Resident #3's annual MDS assessment dated [DATE] reflected Resident #3 was an [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included hypertension (elevated blood pressure), neurogenic bladder (a problem in the brain, spinal cord, or central nervous system that make a person lose control of the bladder) muscle weakness, dementia (diseases that affect memory,…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-04 · 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 observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source. were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 of 4 residents (Resident #1 and #2) reviewed for neglect reporting. The facility failed to report an allegation of neglect to the State Agency when Resident #1 was physically abused by Resident #2, sustaining an injury, on 05/02/25. This failure could place residents at risk for not having allegations of neglect reported which could lead to injury or worsening of condition and…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · Fcited before2025-01-29 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for Food and Nutrition Services. 1. The facility failed to ensure 6 tomatoes in the walk-in refrigerator were not bruised. 2. The facility failed to ensure three of six dietary staff (Dietary [NAME] O, Dietary Aide P and Dietary [NAME] T) used proper hand hygiene while handling and serving food during the lunch meal preparation and service on 01/28/25. 3. The facility failed to ensure five of six dietary staff (Dietary Aide P, Dietary Aide Q, Dietary Aide R, Dietary [NAME] T and Dietary Supervisor) used effective hair restraints while in the kitchen on 01/28/25 during the lunch meal preparation and service. 4. The facility failed to take the temperature of the 2nd container of zucchini and gravy before serving to residents for lunch on 01/28/25. These failures could place residents at risk for food-borne illness if consumed and food contamination . Observation and interview…

    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 before2025-01-29 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to 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 seven of eight hallways (shower rooms on 100, 200, 300, 400, 500, 700, and 800 hallways) reviewed for environment and 1 of 34 residents ( Resident # 109) reviewed for clean linens. 1. The facility failed to ensure the shower rooms were cleaned throughout the day, kept orderly, and maintained in a sanitary and comfortable condition for resident use. 2. The facility failed to ensure Resident #109 had clean linens on 01/28/2024 from 9:27 AM until 11:00 AM. This failure could place residents at risk of exposure to infectious diseases and other unsanitary health hazards. Findings include: 1. In a confidential group interview with 12 residents revealed 8 residents had concerns with the cleanliness of the shower rooms and stated it did not seem like the showers rooms were…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-29 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    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 observation, interview and record review the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for one of 7 residents (Resident#23) reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system was within reach of Resident #23 when the resident was lying in bed . This failure could place residents at risk of being unable to have a means of directly contacting caregivers. Findings include: A record review of Resident#23's MDS quarterly assessment , dated 12/26/24, reflected a [AGE] year-old male with a BIMS score 12 of 15, which indicated moderate cognitive impairment. Resident #23 was admitted to the facility on [DATE] with diagnoses , which included, Stroke (a brain damaged due to a lack of blood flow due to blocked or ruptured blood vessel), drug induced…

    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 before2025-01-29 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 2 of 4 residents (Resident #14 and Resident #31) reviewed for ADLs. 1. The facility failed to ensure Resident #14 had her fingernails trimmed on 01/27/25. 2. The facility failed to ensure Resident #31 had his fingernails cleaned and trimmed on 01/29/25. These failures could place residents at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: 1. Record review of Resident #14's Quarterly MDS assessment, dated 01/09/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #14 had diagnoses which included dementia (diseases that affect memory, thinking, and the ability to perform daily activities), muscle wasting, and anxiety disorder (a common mental health condition characterized by…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-29 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, administering of drugs and biologicals, to meet the needs of each resident for of 3 medication carts 1 (nurses cart hall 100) reviewed for pharmacy services. 1. The facility failed to ensure RN C, who was responsible for Nurses Cart Hall 100, removed medications in unsecure containers from the Nurses Cart. 2. The facility failed to ensure the Nurses Cart Hall 100 did not have an expired insulin pen for Resident #55 These failures could place residents at risk of not having the medication available due to possible drug diversion, diminished effectiveness, and not receiving the therapeutic benefits of the medications. Findings Include: Observation and record review on [DATE] at 10:10 AM of nurses cart hall 100, with RN C revealed: - the blister pack for Resident #89's hydrocodone acetaminophen 5-325 mg tablet (controlled…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-29 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to 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 2 of 8 residents (Resident #9 and Resident #109) reviewed for infection control. The facility failed to ensure CAN J changed her gloves and performed hand hygiene while providing incontinence care to Resident #9 on 01/28/25 . These failures could place residents at risk of cross-contamination and development of infections. Findings include: In an observation on 01/28/25 at 03:24 PM revealed CNA J and CNA B entered Resident #9's room to provide peri care. Both staff washed their hands and put on gloves CNA J unfastened the resident brief and she cleaned his front pubic area with several wipes. CNA J rolled the resident on his side, removed the soiled brief, and wiped the anal area from front to back and then the buttocks, changing to a clean wipe with each swipe. CNA J then pushed the…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-12-27 · tag F0602 — failed to protect residents from theft of their belongings — pattern
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free from Misappropriation of property for one (Resident #1) of 8 residents reviewed for misappropriation of property. The facility failed to protect Resident #1 from misappropriation of property by one of their employees AA. On 06/24/2024 the facility Business Office Manager and Administrator came to know that AA was using Resident#1's bank debit card for unauthorized transactions for the past several months. As a result, Resident #1 lost approximately $25,000.00 from his personal bank account. This failure could place residents at risk of Exploitation/Misappropriation of Property and loss of lifelong earnings. Findings included: Record review of Resident #1's face sheet dated 12/11/2024 revealed Resident #1 was a [AGE] year-old male, with an original admission date of 09/28/2023. Diagnosis included: Cognitive Communication Deficit (Difficulty in communication that arises from impairments in cognitive process),…

    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 before2023-11-18 · 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 observation, interview, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three (Resident #1, Resident #2, and Resident #3) of ten residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #1, Resident #2, and Resident #3's rooms was in a position that was accessible to the resident. This failure could place the residents at risk of being unable to obtain assistance when needed and not get help in the event of an emergency. Findings included: Resident #1 Review of Resident #1's Face Sheet dated 11/18/2023 reflected resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included muscle wasting (loss of muscle leading to its shrinking and weakening) and atrophy (decrease in size of the muscle), aphasia (a comprehension and communication disorder) following cerebral infarction, and hemiplegia…

    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 · E2023-11-18 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    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, interviews, and record reviews, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three (Resident #4, Resident #5, and Resident #6) of five residents reviewed for respiratory care. The facility failed to ensure Resident #4 and Resident #5's mask for breathing treatment were dated and bagged when not in use. The facility failed to ensure Resident #6's nasal cannula (a device used to deliver supplemental oxygen to an individual. It consists of a lightweight tube on which one is connected to the oxygen source and the other end splits into two prongs and are placed in the nostrils) was dated and bagged when not in use. These failures could place the residents at risk of respiratory infections and not having their respiratory needs met. Findings included: Resident #4 Review of Resident #4's Face Sheet dated…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-11-16 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents in 5 of (701, 706, 708, 709, and 711) of twelve resident bedrooms reviewed for resident rights. The facility failed to maintain 5 (701, 706, 708, 709, and 711) bedrooms in a safe, sanitary, and comfortable condition. This deficient practice could place residents at risk of a diminished quality of life due to an unsafe and unmaintained environment. The findings were: Observations on 11/14/2023 between 12:13 PM and 3:10 PM revealed the toilet seat in room [ROOM NUMBER]'s bathroom to be loose and the headboard of the bed closest to the window to be attached to the bed on one side and the other resting on the floor. The toilet seat in room [ROOM NUMBER]'s bathroom to be loose. The bathroom floor and walls in room [ROOM NUMBER] covered in feces, with the room smelling of feces. One resindet was observed wandering into the room then redirected by staff to exit the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-11-16 · 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 3 (Resident #22, Resident 162, and Resident #173) of 8 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #22 had his fingernails trimmed. 2- Resident #162 had his fingernails trimmed and cleaned. 3- Resident #173 had his fingernails trimmed and cleaned. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: 1- Review of Resident #22's Quarterly MDS assessment dated [DATE] reflected Resident #22 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses included quadriplegia (paralysis of all four limbs), and anxiety disorder. Resident #22 had a BIMS score of 014 which indicated Resident #22's cognition was intact. Resident#22…

    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 before2023-11-16 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for 1 (Resident #138) of 4 residents observed for medication administration and 3 medication cart (Nurses Cart 100/200 halls, Medication Aide Cart 400 hall, and Medication Aide Cart 600/800 halls) of 5 medication carts reviewed for pharmacy services in that: 1. The facility failed to ensure MA F administered medications for Resident #138 on time as ordered. 2. The facility failed to ensure medications in unsecure containers were immediately removed from stock. These failures could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving therapeutic effects from their medications as intended by the prescribing physician order. Findings Included: 1. Review of Resident #138's Face sheet, dated 11/15/23, reflected, he was a [AGE] year-old male…

    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 before2023-11-16 · 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 reviewed for kitchen sanitation in that: 1. Facility failed to ensure missing tile floor was repaired in the dish room of kitchen. 2. Dietary Aide N and Dietary Aide O failed to practice appropriate hand hygiene when putting up clean dishes. These failures could place residents at risk for food contamination and food-borne illness. Findings included: Observation on 11/15/23 at 2:25 PM revealed the dish area of kitchen had 15 missing tiles under the sink in the dish area (left of dish machine) and 10 missing tiles on the floor to the right of the dish machine revealing water damage with yellowish/brownish stains on floor where the missing tiles were. Observation on 11/15/23 at 2:27 PM revealed Dietary Aide N touched his phone and then put up clean trays which just came out of the dish machine still dripping. He continued to stack clean wet trays with dripping water on top…

    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 before2023-11-16 · 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 observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #86) of ten residents, six (200, 400, 500, 600, 700, and 800 Halls) of eight clean linen closets, and 2 of 4 medication carts reviewed for infection control. 1. LVN H failed to change gloves and perform hand hygiene during wound care to Resident #86. 2. The facility failed to ensure clean linen closets were kept sanitary and free of personal care and clothing items. 3. The facility failed to ensure the Silent Night pill crushers were clean for 2 of 4 medication carts. These failures could place residents at risk of infection, slow wound healing, and or a decline in health. Findings included: 1. Review of Resident #86's Quarterly MDS assessment dated [DATE] reflected Resident #86 was a [AGE] year-old female admitted…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-16 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan that included measurable goals and objectives, and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #38) of 3 residents reviewed for comprehensive care plans. The facility failed to ensure Resident #38 had a person-centered care plan to include significant weight loss interventions. This failure could place resident at risk of not having needs identified and addressed. Findings included: Record review of Resident #38 MDS dated [DATE] revealed she is a 63- year-old female admitted to the facility on [DATE] with diagnosis of encephalopathy (a group of conditions that cause brain dysfunction), vascular dementia (general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain).…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-16 · 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 medications were stored and labeled in accordance with currently accepted professional principles on 1 medication cart (Nurses Cart Hall 900) of 5 medication carts observed for medication storage in that: Facility failed to ensure medication cart (Nurses Cart Hall 900) did not contain a bag of snack mixed with medication in the second drawer of the medication cart. This failure could place residents at risk of receiving contaminated medication. The findings include: During an observation and interview on 11/14/23 at 12:53 PM, in the medication cart in the second drawer of the cart was a snack bag (Simply Nature Raw almonds, Pecans and Pistachio Kernels), the net weight 8 ounces, the bag was halfway empty. LVN G stated she was responsible for the medication cart, she stated she was not aware of the snack bag in the medication cart, and she overlooked it this morning. LVN G stated food or drink should not be in the medication cart. She said the DON and ADON double checked the medication carts but was…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-09-27 · tag F0712 — pattern
    Ensure that the resident and his/her doctor meet face-to-face at all required visits.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter or alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner or clinical nurse specialist for four (Residents #1, #2, #4 and #5) of four residents reviewed for physician services. The facility failed to ensure Residents #1, #2, #4 and #5 were seen by their attending physician at least once every 60 days. The attending physician's extenders were completing all visits for the residents, not alternating visits with the physician. The failure could place residents at an increased risk of not receiving appropriate and adequate medical care and a lack of oversight by the physician, which could place the residents at risk of harm and health decline. Findings included: 1. Record review of Resident #1's Face Sheet (undated) reflected she was a [AGE] year old…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-09-27 · tag F0949 — failed to train staff on dementia and abuse — pattern
    Provide behavior health training consistent with the requirements and as determined by a facility assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide mandatory effective behavioral health training for six (ADON B, RN F, CNA Q, CNA R, LVN I, CNA U) of six facility staff hired since October 2022 for required training. The facility failed to ensure newly hired staff in the past year (since October 2022)- ADON B, RN F, CNA Q, CNA R, LVN I and CNA U completed behavioral health training upon hire as was listed as a training requirement in the facility's annual assessment. The facility failure could place residents at risk of not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being due to lack of staff training and knowledge in working with residents who have mental health issues. Findings included: Record review of the facility assessment provided by the ADM on 09/13/23 reflected it was updated and reviewed by the QAPI committee on 09/12/22 and reflected the facility would complete training upon hire, annually and PRN for Caring for Residents with Mental and Psychosocial Disorders. The facility assessment reflected they had…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-27 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must have evidence that all alleged violations are thoroughly investigated and prevent further abuse, neglect, exploitation, or mistreatment while the investigation is in process for two (Residents #1 and #2) of five residents reviewed for abuse and neglect. The facility failed to thoroughly investigate an unwitnessed resident to resident allegation with Residents #1 and #2,. The facility failed placed residents at risk of being sent out for unnecessary psychiatric and psychological evaluations, unnecessary increases in psychotropic medications, lack of knowledge of the events which could cause the wrong interventions, and lack of due diligence in investigating resident to resident altercations. Findings included: Record review of Resident #1's Face Sheet (undated) reflected she was a [AGE] year-old female admitted to the facility on [DATE] with active…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-27 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for one (Resident #5) of ten residents reviewed for care plans. Resident #5's care plan was not individualized and did not address her wounds. This failure could place residents at risk of not receiving individualized care and services to meet their needs. Findings included: Record review of Resident #5's Face Sheet (undated) reflected she was a [AGE] year old woman admitted to the facility on [DATE]. Her active diagnoses included parastomal hernia with obstruction (a condition wherein abdominal contents, typically the bowel or greater omentum (a fold of peritoneum connecting the stomach with other abdominal organs), protrude through abdominal integuments surrounded by the hernia sac at…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-27 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that in accordance with accepted professional standard and practices, medical records were accurately documented for one (Resident #5) of five residents reviewed for clinical records accuracy. The facility failed to document wound care orders on Resident #5's TAR. The facility failure could place residents at risk of inaccurate clinical records. Findings included: Record review of Resident #5's Face Sheet (undated) reflected she was a [AGE] year old woman admitted to the facility on [DATE]. Her active diagnoses included parastomal hernia with obstruction (a condition wherein abdominal contents, typically the bowel or greater omentum (a fold of peritoneum connecting the stomach with other abdominal organs), protrude through abdominal integuments surrounded by the hernia sac at the location of formed stoma). Record review of Resident #5's annual MDS assessment dated [DATE] reflected she rarely understood others and her BIMS score was a 03, which…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-01 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (LVN A) of two staff observed for infection control in that: LVN A failed to create a clean area prior to and during wound care, lying treatment supplies on top of treatment cart, lying the treatment supplies on the dirty overbed table, change soiled gloves and wash hands during wound care to Resident #1. This failure could place residents at risk for spread of infection through cross-contamination. Findings included: Review of Resident #1's quarterly MDS assessment, dated 07/11/23, reflected he was a [AGE] year-old male admitted to the facility on [DATE], with the following diagnoses: diabetes, dementia, psychotic disturbance, mood disturbance, and anxiety disorder. Resident #1 was alert and oriented for decision making.…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to 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 2 of 52.3-0.3 vs chain
Health inspection 1 of 52.2-1.2 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 5Sunny Springs Nursing & RehabSulphur Springs, TX 2 of 5White Acres Wellness & RehabilitationEl Paso, 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
NOCONA HOSPITAL DISTRICTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 12/01/2015
MEEKINS, GREGIndividualCORPORATE OFFICERsince 12/01/2015
DALLAS TEXAS HEALTHCARE LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2015
GARETZ, DAVIDIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2015
GURWITZ, SOLOMONIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/28/2025
HAGINS, ELIZABETHIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/28/2025
KAPLAN, ESTHERIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/03/2025
KAPLAN, MORDECHAIIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 03/10/2025
MINDLE, ADAMIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/03/2025
UNGER, JEFFREYIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/03/2025
3326 BURGOYNE STREET TX, LLCOrganizationADP OF THE SNFsince 12/01/2015
CONTINUUM REHAB GROUP LLCOrganizationADP OF THE SNFsince 12/01/2015
DALLAS SKY REALTY, LLCOrganizationADP OF THE SNFsince 12/01/2015
FIRST TEXAS PROPCO, LLCOrganizationADP OF THE SNFsince 12/01/2015
GIBRALTAR TRUSTOrganizationADP OF THE SNFsince 12/01/2015
HARVEST REALTY LLCOrganizationADP OF THE SNFsince 12/01/2015
MONTGOMERY SKY TRUSTOrganizationADP OF THE SNFsince 12/01/2015
OPCO CA SKILLED MGMT INC.OrganizationADP OF THE SNFsince 12/01/2015
OPCO TEXAS SKILLED MGMT LLCOrganizationADP OF THE SNFsince 12/01/2015
BROWN, DEANDREIndividualADP OF THE SNFsince 04/05/2018
ROBERTS, DAVIDIndividualADP OF THE SNFsince 10/23/2023

11 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.

$14.6M
Net patient revenuemost recent cost report
-1.4%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 79%Medicare 2%Other / private 18%

About 79% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$227per resident / day
operating cost
$6,899per month
≈ monthly operating cost
$224per 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 455653. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-14, 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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