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Decatur Medical Lodge

701 W Bennett Rd, Decatur, TX 76234 · For profit - Limited Liability company · 124 certified beds · (940) 626-2800 Medicare & Medicaid certified

Call the home — (940) 626-2800 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0607, F0609) — most recent Oct 20231 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$14,518 in federal fines
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $14,518 in federal fines (most recent 2023-08-29)
  • its payroll-based staffing rating is low (1/5)
  • its facility-reported quality-measure rating is low (2/5)
  • nursing-staff turnover (71%) runs well above the national median (45%)

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

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

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
902 Preskitt Rd · (940) 626-8073 · Call to confirm hours
Pharmacy
800 Medical Center Dr Ste A · (940) 627-5343 · Call to confirm hours
Grocery
1202 S FM-51 · (940) 627-6438 · Call to confirm hours
Park
Football Fields · Typically dawn to dusk
Place of worship

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 2 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 1 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased18.1%15.8%15.4%worse
Long-stay residents who lose too much weight1.8%3.0%5.4%better
Long-stay residents with a catheter left in their bladder0.3%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms2.1%2.4%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury5.4%3.3%3.3%worse
Long-stay residents whose ability to walk worsened2.5%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication10.3%18.0%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers2.8%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control11.3%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table14.0%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication1.7%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine98.3%88.0%79.4%better
Short-stay residents rehospitalized after admission23.0%25.7%22.6%typical
Short-stay residents with an outpatient ER visit21.2%12.3%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.972.171.67worse
Long-stay outpatient ER visits per 1,000 resident days2.862.061.80worse

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

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

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

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

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

50.4% 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 133 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

50.4%U.S. median 51.5%
Got home and stayed home
11.2%U.S. median 10.7%
Went back to hospital
42.4%U.S. median 56.6%
Met the expected recovery
0.81U.S. median 0.31
Therapy hours / resident / day
0.37hours / resident / day
Physical therapy
0.35hours / resident / day
Occupational therapy
0.09hours / resident / day
Speech therapy

Met the expected recovery: 42.4% 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 59 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 0.81 therapist hours per resident per day in 2026Q1 — more than 95% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF50.4%CMS range 43.4–57.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.2%CMS range 8.4–14.610.7%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 discharge42.4%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 discharge59.3%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 discharge40.7%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 identified96.9%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 setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this 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 discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this 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 worsened2.1%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 hospitalization7.5%CMS range 4.4–12.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.441.02Oct 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

0.22
RN hours/ resident / day
1.01
LPN hours/ resident / day
1.83
Aide hours/ resident / day
3.06
Total nurse hours/ resident / day
0.17
RN hoursweekends
71.3%
Total nursing turnover
60.0%
RN turnover

How full it usually is: this home is certified for 124 beds and averages 102.2 residents a day — about 82% occupied, or roughly 22 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 3.06 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.22 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.83 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 2.67 hrs/resident/day on weekends vs 3.22 on weekdays — 17% thinner on weekends. RN hours go from 0.24 to 0.17 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 71% is well above 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

7
deficiencies at the latest standard inspection (2026-04-28)
5
at the previous standard inspection (2025-02-06)

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.

29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2023-10-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the resident environment was free of accident and hazards as was possible for one resident (Resident #1) of three residents reviewed for accidents and hazards. Driver C failed to follow proper safety measures in securing Resident #1 in the van while driving the resident. An Immediate Jeopardy (IJ) was determined to have existed from [DATE] through [DATE]. The IJ was removed on [DATE] because the facility implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure placed residents at risk of severe injury or death. Findings include: Record review of Resident #1's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included altered mental status, kidney cancer, and dialysis. Resident #1 was noted to be her own responsible party. Review of Resident #1's Quarterly MDS assessment, dated [DATE], reflected Resident #1 had…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · E2026-04-28 · tag F0628 — pattern
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    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 reviews, the facility failed to notify the resident and/or resident's representative(s) in writing of the discharge, reasons for the move, and right to appeal in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 2 (Resident #14 and Resident #109) of 6 residents reviewed for discharge planning. The facility failed to notify the residents or the residents' representative or POA of the transfer or discharge with the reasons for the move in writing in a language and manner they understand for Resident #14 and Resident #109.The facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State LTC Ombudsman involving Resident #14 and Resident #109These failures could place residents at risk of being discharged without alternative placement, discharge options, their rights to appeal and access to advocacy services. A record…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-04-28 · tag F0676 — failed to keep up residents' daily-living abilities — pattern
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    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 based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility provided the necessary care and services to ensure that a resident's abilities in activities of daily living did not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable for two (Resident #96 and Resident #34) of 5 residents, reviewed for positioning during meals. The facility failed to ensure CNA A correctly positioned Resident #96 for feeding. The facility failed to ensure CNA E correctly positioned Resident #34 for feeding. This failure placed residents at risk for aspiration and choking due to poor positioning while eating. Findings included: Review of Resident #96's Quarterly MDS Assessment, dated 04/02/26, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her cognitive skills for daily 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-04-28 · tag F0805 — failed to prepare food in a form residents can eat — pattern
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure food was prepared in a form designed to meet individual needs for one (Resident #63) of 8 residents, reviewed for puree' meals. The facility failed to ensure [NAME] F correctly prepared a puree' meal for Resident #63. This failure placed residents at risk for aspiration and choking due to food not being prepared correctly.Findings included: Review of Resident #63's Quarterly MDS Assessment, dated 03/05/26, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her BIMS score was 6 indicating her cognitive skills were severely impaired. Her diagnoses included stroke, seizure disorder, and malnutrition. The resident was on a therapeutic diet. Review of Resident #63's Order Summary Report dated 04/10/26, reflected:Pureed texture, regular consistency diet Review of Resident #63's Comprehensive Care Plans, dated 11/03/25, reflected:Nutritional problem or potential nutritional problem.At risk for…

    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 before2026-04-28 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety.The facility failed to ensure that only disposable paper towels were disposed of in the garbage receptacle at handwashing sink #1.The facility failed to ensure food items in the dry storage room were properly stored, sealed, and protected from exposure to air in accordance with professional food service standards.The facility failed to ensure food items in the walk-in freezer were properly stored, sealed, and protected from exposure to air.These failures could place residents at risk for food-borne illness, cross contamination, and infection.During an observation of the #1 handwashing sink's garbage receptacle on 04/26/2026 at 9:54 a.m., the following was revealed:Handwashing sink #1 had a garbage receptacle that contained items other than disposable paper towels, including disposable gloves, a plastic lid, and a straw.During an interview on…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-28 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment one (Resident #2) of 4 residents, reviewed for PASARR. The facility failed to ensure the MDS Coordinator referred Resident #2 for a PASARR evaluation or PASARR Level 2 screening. This failure placed residents at risk of not receiving PASARR services they could potentially receive.Findings included: Record review of Resident #2's Annual MDS Assessment, dated 02/26/26, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His BIMS score was 11 indicating his cognitive skills were moderately impaired. His diagnoses included post-traumatic stress disorder, anxiety disorder and depression. Record review of Resident #2's Comprehensive Care Plans, dated 03/27/25, reflected:At risk for a mood problem…

    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 before2026-04-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility to ensure each resident received adequate supervision and assistance devices to prevent accidents for residents for 1 (Resident #13) of 5 residents reviewed for devices. The facility failed to maintain Resident #13's manual wheelchair, which was missing the right-hand armrest and had a cracked and worn left armrest, exposing he resident to possible skin breakdown. This failure could place residents at risk of being uncomfortable and of injury from equipment not properly maintained.Findings included:Record review of Resident #13's Face Sheet, dated 04/27/2026, reflected Resident #13 was a [AGE] year-old male, admitted on [DATE], with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side (paralysis of the left side after a stroke), End Stage Renal Disease (kidney failure), and Unspecified Convulsions.Record review of Resident #13's Comprehensive MDS, dated [DATE], reflected a BIMS Score of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-28 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #86) of 5 residents, reviewed for infection control. The facility failed to ensure CNA I performed hand hygiene during incontinence care for Resident #86. This failure placed residents at risk for infection due to not performing hand hygiene.Findings included: Review of Resident #86's Quarterly MDS Assessment, dated 04/01/26, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her BIMS score was 7 indicating her cognitive skills were severely impaired. Her diagnoses included heart failure and non-Alzheimer's dementia. Review of Resident #86's Comprehensive Care Plans, dated 02/26/26, reflected:ADL self-care performance deficit related to muscle…

    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 · E2025-06-25 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents received and were provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for two of two residents (Resident #1 and #2) reviewed for dietary services. The facility failed to provide palatable food served at an appetizing temperature and taste to Residents #1 and #2. This failure could place residents at risk of weight loss, altered nutritional, status, and diminished quality of life. Findings include: 1. Record review of Resident #1's, undated, admission Record revealed a [AGE] year-old-male who was admitted to the facility on [DATE]. Resident #1 had a diagnosis which included Parkinson's Disease without dyskinesia, without mention of fluctuations (A neurodegenerative disease primarily affecting the central nervous system affecting both motor and non-motor systems but without the writhing/wriggling/dramatic movements or fluctuations). Record review of Resident #1's Care Plan, 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-02-06 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored in locked compartments for one of eight medication carts (Nurse med cart #1) in that: The facility's nurse medication cart (Nurse med cart #1) was left unlocked, unattended, and out of LVN B's view outside room [ROOM NUMBER] on 02/04/25. This failure placed residents at risk of their medications being stolen or misused and health complications related to accidental ingestion of drugs and/or biologicals, including hospitalization and death, Findings included: During an observation in 300 hallways on 02/04/25 from 2:39 PM to 2:50 PM, the Nurse medication cart (Med cart #1) was unlocked, with drawers able to be opened. There were insulins (medications that can lower blood sugars), prescription medications pills, over the counter medications, and breathing treatments inhalers containing albuterol, (a medication that causes nervousness, shakiness, throat/nasal irritation, muscle aches, and…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-02-06 · 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 prevention and control measure designed to provide a safe, sanitary environment to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents (Resident #3 and Resident #81) reviewed for infection control in that: 1.CNA A failed to put on Personal Protective Equipment (PPE) while providing perineal care to Resident #3, who is on EBP. 2. LVN B failed to put on PPE while administering medications and tube feeding via G-tube for Resident #81 who was on EBP for G-tube (a g-tube is a feeding tube that is placed through the abdominal cavity area into the stomach for nutritional purpose and medication for individual who have difficulty swallowing). These deficient practices could place residents and nursing staff at risk of transmission of communicable diseases and infections. Findings include: 1.Review of Resident #3 face sheet, dated 2/4/2025, revealed that Resident #3 is a…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · D2025-02-06 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights for 2 of 4 residents (Resident #4 and Resident #19) reviewed for care plans in that: The facility failed to ensure that Resident #4 and Resident #19 use of bed rails/grab bars/mobility bars/transfer bars were documented in their care plans. The facility's failure placed residents requiring care at risk of not having their individual needs met, not receiving necessary care and services, and a failure to ensure continuity of care. Findings included: Record Review of Resident #4's Face Sheet reflected a [AGE] year-old male who initially admitted to the facility on [DATE]. Resident #4 had relevant diagnoses of Parkinson's Disease (progressive neurodegenerative disorder that affects movement, balance, and coordination) with dyskinesia (involuntary, uncontrolled movements), with fluctuations; Alzheimer's Disease (progressive…

    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 · D2025-02-06 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications for 1 (Resident #81) of 4 residents reviewed for enteral nutrition in that: 1.LVN B failed to obtain physician orders for water to flush Resident #81's G-tube before medication administration and after medication administration via the G-tube. 2. LVN B failed to hold tube feeding for 30 minutes after medication administration for Resident #81 per facility policy. 3. LVN B pushed all medication and water with a syringe and plunger instead of using gravity gentle flow (this is a method used by attaching a feeding syringe without the plunger to allow water, medications and food to enter the stomach vis G-tube gently without force of pushing) to administer medications and water via G-tube for Resident #81. These deficiency practices could affect residents who receive tube feedings by not receiving the appropriate nutrition/ hydration…

    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 · D2025-02-06 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    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 assess the risks and benefits of bed rails and grab bars with the resident or resident representative or obtain informed consent prior to installation for one (Resident #4) of four resident rooms observed and reviewed for bed rails/enabler bars. The facility failed to have evidence of informed consent and assessment of the resident for risk of entrapment for bed rails or grab bars for Resident #4. This failure could place residents who used bed rails/grab bars at risk of the resident not being assessed for bed rails or grab bars, resident/responsible party not being aware of the risks, and informed consent not being obtained from the resident or responsible party. Findings included: Record Review of Resident #4's Face Sheet reflected a [AGE] year-old male who initially admitted to the facility on [DATE]. Resident #4 had relevant diagnoses of Parkinson's Disease (progressive neurodegenerative disorder that affects movement, balance, and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-10 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 1 (Resident #1) of 4 residents reviewed for quality of care. The facility failed to ensure Resident #1's oxygen tubing was dated. This failure placed the residents at risk for infections and respiratory related complications. The findings were: Record Review of Resident #1 admission record reflected; [AGE] year-old-female with an initial admission date of 08/07/2023 and a preliminary diagnosis of: CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED Record Review of Resident #1's MDS Optional State assessment dated [DATE] reflected; Resident #1 had a BIMS score of 07 (Severe cognitive impairment). Record Review of Resident #1's Care Plan reflected; Focus: The resident has oxygen therapy r/t Chronic Respiratory illness;…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-17 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention for one (Resident #1) of eight residents reviewed for notification. LVN A failed to notify Resident #1 physician after resident fell in her room on 04/17/24. LVN A failed to notify Resident #1's responsible party after Resident# 1had a fall in her room on 04/17/24. These failures could place residents at risk for delayed physician intervention and risk of families not receiving notification of change in condition of residents. Findings included: Record review of Resident #1 's admission record dated 04/17/24, revealed an [AGE] year-old female that was admitted to the facility on [DATE]. Her diagnoses included rheumatoid arthritis (a condition in which the body attacks its…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-12-14 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to store, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to date and label food items in the walk-in refrigerator of the facility's kitchen. These failures affected residents by placing them at risk for contamination and food-borne illness. Findings included: An observation of the walk-in refrigerator on 12/12/23 at 8:50 AM revealed: - 1 basket of sandwiches that appeared to contain peanut butter and jelly undated and unlabeled - 1 small Tupperware container with 4 cut up pieces of tomato undated and unlabeled - 1 piece of meat that appeared to be ham in a Ziploc bag undated and unlabeled - 2 Large Ziploc bags containing a sandwich, a pack of crackers, cookies and a water bottle. Both bags undated and unlabeled - 2 Large zip loc bags with what appeared to be fried chicken undated and unlabeled - 1 Large Ziploc bag with several items individually wrapped with aluminum foil undated and unlabeled - 1 cube shaped container…

    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 before2023-12-14 · tag F0925 — failed to control pests — pattern
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain an effective pest control program to keep the facility free of pests for one (Hall 400) of four halls. The facility failed to keep the environment free of flies. This failure could affect residents by placing them at risk for the potential spread of infection, food-borne illness, and decreased quality of life. Review of Resident #57's face sheet, dated 12/13/2023, reflected he was a [AGE] year-old male, admitted on [DATE] with diagnoses of unspecified dementia with behavioral disturbance, heart disease, and history of stroke. Review of Resident #57's MDS assessment, dated 12/05/23, reflected he was usually able to understand others and to be understood by them. He had a BIMS score of 14, indicating intact cognition. Resident #57 exhibited no behaviors or psychosis during the assessment period. He required partial to moderate assistance with most of his ADLs. Review of Resident #69's face sheet, dated 12/13/2023, reflected he was a…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-14 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    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 food was prepared in a form designed to meet individual needs for one (lunch) of two meals reviewed. Cook C failed to ensure the puree bread was prepared to the desired consistency. This placed residents at risk, who received pureed meals from the kitchen, of choking. Findings included: Record review of the facility's Diet Roster dated 12/13/23 revealed the facility had 5 Residents with a puree diet. An observation on 12/13/23 at 1:32 PM revealed the pureed bread was not the correct consistency. It was thick and lumpy. The consistency was not smooth. The lumps were not hard, but they were firm. An observation and interview on 12/13/23 at 1:40 PM revealed the DM tasted the pureed bread. He stated the pureed bread was pretty thick and should have been looser and smoother. The Dietary Manager stated he did not prepare the pureed bread. He said if he did, he would have added chicken stock to the puree bread to smoothen it. He stated they used the recipe to prepare puree food items and they added either…

    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 · D2023-12-14 · tag F0814 — failed to dispose of garbage properly — isolated
    Dispose of garbage and refuse properly.
    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 dispose of garbage and refuse properly for the facility's main dumpster reviewed for garbage disposal. 1. The facility failed to ensure the garbage storage area was maintained in a sanitary condition to prevent the harborage and feeding of pest and failed to ensure garbage dumpster lids remained closed. This failure could place residents at risk of contracting disease by attracting pest and disease carrying rodents. Findings included: During an observation on 12/13/2023 at 4:40 PM with CNA A of the garbage disposal areas by the trash dumpsters revealed, a busted open trash bag with food debris on the ground, a broken fluorescent bulb (broken glass), and used medical gloves. During an interview on 12/13/23 at 11:06 AM with Maintenance Director A, he stated that he worked at the facility part-time, about 2 hours a day, and was the only one currently in the department. Maintenance Director A stated that he has been coming to this facility to work part-time for 4 weeks, since the full-time maintenance worker got…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-14 · 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 disease and infections for 1 (Residents #64) of 10 residents reviewed for infection control. The facility failed to ensure CNA D washed her hands after barehanded carrying a dirty tray out of a communicable disease isolation room for Resident #242, before barehanded touching Resident #64's bedside table, and barehanded touching Resident #64's call light. The facility failed to ensure CNA D sanitized her hands after exiting Resident #64's room. This failure could place residents at risk of communicable infectious diseases. Findings included: Review of Resident # 242's admission Record dated 12/13/23, reflected he was a [AGE] year-old male, admitted to the facility 12/11/23 with diagnoses of cellulitis (a serious bacterial infection in the wound), both legs…

    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 · E2023-11-29 · 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 interview and record review, the facility failed to provide pharmaceutical services to ensure accurate administration and documentation of medications for 2 of 3 residents (Resident #1, and #2) reviewed for pharmacy services and medication administration by two CMA (CMA A, CMA B) in that: The facility failed to give mediations in a timely manner for several medications scheduled at 7:00AM , 7:30AM and 9:00AM for Resident #1 and #2 the morning of 11/29/2023 during medication pass with CMA A and CMA B. This failure placed residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. The findings included: Record review of the admission face sheet, dated 11/29/23, reflected Resident #1 was a [AGE] year-old female admitted on [DATE] with a diagnosis (illness) included: depression, chronic kidney disease, bacterial infection of unspecified cite, and hypertension (high blood pressure). Record review of the MAR for Resident #1 dated 11/29,2023, reflected times…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-11 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable and homelike environment, which included but not limited to receiving treatments and supports for daily living safely for 1 of 26 residents that reside on Hall 100 reviewed for environment. The facility failed to ensure the hallway carpet on Hall 100 was not frayed. This deficient practice could place residents at risk for a diminished quality of life and a diminished clean and homelike environment. The findings were: Record review of Resident #7's, undated, face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included: Symbolic Dysfunctions and Heart Disease. Record review of Resident #7's Care Plan, dated 03/13/23, revealed Problem onset: Risk for Falls. Approaches: Assist me with one staff member for all ambulation. Observation on 09/27/23 at 11:30 AM at the entrance of Hall 100 revealed a tear in the carpet measuring…

    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 · D2023-10-11 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement the facility's own written abuse and neglect prevention policy and procedure for one (Resident #1) of eight residents reviewed for abuse and neglect reporting. The Administrator failed to report an incident which occurred when Driver C was driving Resident #1 to an appointment without her seatbelt on, and the resident fell, bumping her head (no injury) and sustaining a skin tear to her forearm. This failure could place residents at risk of being abused or neglected and lack of oversight by a state agency. Findings included: Review of the facility policy for Abuse Investigation and Reporting, dated 10/15/22, reflected the following: Policy Statement All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ('abuse') shall be promptly reported to local, state and federal agencies and thoroughly investigated by facility management ( .) Policy Interpretation and…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-11 · 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 and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury for one (Resident #1) of eight residents reviewed for abuse and neglect reporting. The Administrator failed to report an incident which occurred when Driver C was driving Resident #1 to an appointment without her seatbelt on, and the resident fell, bumping her head (no injury) and sustaining a skin tear to her forearm. This failure could place residents at risk of being abused or neglected and lack of oversight by a state agency. Findings included: Review of the facility policy for Abuse Investigation and Reporting, dated 10/15/22, reflected the following: Policy Statement All reports of resident…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-08-29 · tag F0802 — failed to prepare enough nourishing food — pattern
    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 2 of 8 dietary staff (Cook A and DA B) reviewed for competencies, in that: The facility failed to ensure [NAME] A and DA B had a Food Handling Certificate prior to working in the facility kitchen. This failure could place residents who consume food prepared in the facility kitchen at risk of foodborne illness due to being served by improperly trained staff. The findings included: Record review of [NAME] A's personnel file information revealed [NAME] A was a full-time cook, with a hire date of 03/09/23. No documentation of a food handler's certificate was found in [NAME] A's personnel information provided to surveyor. Record review of DA B's personnel file information revealed DA B was a full-time dietary aide, with a hire date of 07/28/23. No documentation of a food handler's certificate was found in DA B's personnel information provided to surveyor by the facility. Observation on…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-08-29 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: - The facility failed to ensure 4 bottles of cleaning products were not stored in dry storage - The facility failed to ensure cracked eggs were not stored in the walk-in cooler - The facility failed to ensure vegetables with fuzzy black and brown substances on them, were not stored in the walk-in cooler - The facility failed to ensure foods stored in the walk-in cooler were properly sealed, labeled and dated - The facility failed to ensure cooler temperatures were monitored and recorded since 07/17/23 These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation of the kitchen's dry storage area and walk in cooler on 08/29/23 at 11:50 a.m. to 12:08 p.m., revealed the following: - Four 1-gallon bottles of Essential Disinfectant Ultra Bleach were stored on a rolling rack, also holding…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-29 · tag F0925 — failed to control pests — isolated
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review the facility failed to maintain an effective pest control program so that facility was free of pests and rodents for the facility's only kitchen. The facility did not maintain an effective pest control program to ensure the facility was free of flies in the kitchen. These findings could place residents at risk for an unsanitary environment and a decreased quality of life. The findings included: Record review of the facility's pest control binder revealed pest control visited the facility bi-weekly to treat for pests and insects. The kitchen was last treated for flies on 08/21/23. Observation of the facility's kitchen on 08/29/23 at 12:09 p.m., revealed approximately six flies flying around [NAME] A, as she took food temperatures before lunch was served. The flies were observed landing on food preparation stations that were not in use and on top of the plate warming station and on eating utensils wrapped in napkins. Further observation of the kitchen two rolls of fly tape hanging from the ceiling of the kitchen near the door next…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-10-11 · tag F0809 — failed to serve meals on a reasonable schedule — widespread
    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 observation, interview and record review the facility failed to ensure each resident received and the facility provided at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests and plan of care for one meal (Lunch on 09/27/23) observed for frequency of meals. The facility failed to serve the 09/27/23 lunch meal on time at the scheduled time. This failure could place residents at risk for decreased meal satisfaction, decreased intake, loss of appetite, side effects from medication given without food, and diminished quality of life. The findings include: Record review of Resident #5's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included: Aphasia following Cerebral Infarction and Chronic Viral Hepatitis C. Record review of Resident #5's Care Plan, dated 07/26/23, revealed Problem/Need: Nutritional Risk; Goal and Target: Will…

    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

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

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

Fines & penalties

$14,518 in federal fines across 1 penalty.

  • $14,518 — penalty dated 2023-08-29

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

Part of a chain

This home belongs to PRIORITY MANAGEMENT — 38 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 52.9-0.9 vs chain
Health inspection 3 of 53.2-0.2 vs chain
Staffing 1 of 51.6-0.6 vs chain
Quality measures 2 of 53.4-1.4 vs chain
The other 37 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Alpine Skilled Nursing and RehabilitationRuston, LA 1 of 5Bridgeport Medical LodgeBridgeport, TX 1 of 5Camelot Rehabilitation At Magnolia ParkLafayette, LA 1 of 5Colonial Oaks Skilled Nursing and RehabilitationBossier City, LA 1 of 5Hilltop Park Rehabilitation And Care CenterWeatherford, TX 1 of 5Pilgrim Manor Skilled Nursing and RehabilitationBossier City, LA 1 of 5Shreveport Manor Skilled Nursing & RehabilitationShreveport, LA 1 of 5St Joseph Skilled Nursing and RehabilitationMonroe, LA 1 of 5The Bradford Skilled Nursing And RehabilitationShreveport, LA 1 of 5The Guest House Skilled Nursing and RehabilitationShreveport, LA 2 of 5Booker T. Washington Skilled Nursing and RehabilitShreveport, LA 2 of 5Resthaven Living CenterBogalusa, LA 2 of 5Ridgmar Medical LodgeFort Worth, TX 3 of 5Broadmoor Medical LodgeRockwall, TX 3 of 5Camelot Of BroussardBroussard, LA 3 of 5Chateau St. James Rehab And RetirementLutcher, LA 3 of 5Louisiana Extended Care Hospital Of LafayetteLafayette, LA 3 of 5Mabank Nursing CenterMabank, TX 3 of 5Royse City Medical LodgeRoyse City, TX 3 of 5The Homestead of DenisonDenison, TX 3 of 5The Woodlands Healthcare CenterLeesville, LA 3 of 5Timber Springs Rehab and RetirementSpringhill, LA 4 of 5Belterra Health & RehabMcKinney, TX 4 of 5College Park Rehabilitation And Care CenterWeatherford, TX 4 of 5Jo Ellen Smith Convalescent CenterNew Orleans, LA 4 of 5Mansfield Medical LodgeMansfield, TX 4 of 5The Parks at Garland Healthcare and RehabGarland, TX 4 of 5Victoria Gardens Of AllenAllen, TX 4 of 5Victoria Gardens of FriscoFrisco, TX 4 of 5Vista Ridge Nursing & Rehabilitation CenterLewisville, TX 4 of 5Windmill Village Rehabilitation & Care CenterLubbock, TX 5 of 5Camelot BrooksideJennings, LA 5 of 5Chateau D'Ville Rehab and RetirementDonaldsonville, LA 5 of 5Chateau Terrebonne Health Care CenterHouma, LA 5 of 5Grapevine Medical LodgeGrapevine, TX 5 of 5Spring Lake Skilled Nursing And RehabilitationShreveport, LA 5 of 5Springtown Park Rehabilitation And Care CenterSpringtown, TX

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
DECATUR HOSPITAL AUTHORITYOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 03/01/2025
CARETRUST REIT INCOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 03/01/2025
CTR PARTNERSHIP LPOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 03/01/2025
SCROGGINS, BRIANIndividualCORPORATE OFFICERsince 03/01/2025
PMG OPCO DECATUR LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/11/2025
BAUDER, WILLIAMIndividualOPERATIONAL/MANAGERIAL CONTROLsince 03/01/2025
BOULWARE, DOUGLASIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 02/11/2025
BOULWARE, STEVENIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 02/12/2025
BRIDGEPOINTE FINANICAL SERVICES, LLCOrganizationADP OF THE SNFsince 03/01/2025
INNOVATIVE NURSE CONSULTING, LLCOrganizationADP OF THE SNFsince 03/01/2025
PRIORITY MANAGEMENT GROUP, LLCOrganizationADP OF THE SNFsince 03/01/2025
PROGRESSIVE REHAB SOLUTIONS, LLCOrganizationADP OF THE SNFsince 03/01/2025
PINEGAR, JOHNIndividualADP OF THE SNFsince 03/01/2025
RICHARDSON, JOHNIndividualADP OF THE SNFsince 03/01/2025

CMS files one row per role, so the 17 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted.

8 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.

$10.4M
Net patient revenuemost recent cost report
-0.2%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 9%Medicare 18%Other / private 73%

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$359per resident / day
operating cost
$10,899per month
≈ monthly operating cost
$358per day
avg. revenue, all payers

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

What families pay in TX

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 676209. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-28, 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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