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Denton Rehabilitation And Nursing Center

3345 Medpark Dr., Denton, TX 76210 · Government - Hospital district · 94 certified beds · (940) 387-8508 Medicare & Medicaid certified

Call the home — (940) 387-8508 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0604) — cited May 2025
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)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • 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
  • its facility-reported quality-measure score sits well above its independent inspection score

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3001 FM 2181 Ste 400 · (214) 222-8150 · Call to confirm hours
Pharmacy
4400 Teasley Ln Ste 100 · (940) 382-1618 · Call to confirm hours
Grocery
Kroger0.7 mi
5021 Teasley Ln · (940) 380-4100 · Call to confirm hours
Park
3150 Mulholland Rd · Typically dawn to dusk
Place of worship
Refresh0.4 mi
2650 Oakmont Dr · (940) 220-6736

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 4 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 rating4★
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 increased27.4%15.8%15.4%worse
Long-stay residents who lose too much weight2.2%3.0%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms5.0%2.4%6.5%worse 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 injury3.9%3.3%3.3%worse
Long-stay residents whose ability to walk worsened29.1%14.0%16.1%worse
Long-stay residents on antianxiety or hypnotic medication19.1%18.0%18.9%typical
Long-stay residents given the seasonal flu vaccine97.1%98.0%95.3%typical
Long-stay residents with pressure ulcers1.1%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 table1.2%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.2%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine82.8%88.0%79.4%typical
Short-stay residents rehospitalized after admission27.1%25.7%22.6%worse
Short-stay residents with an outpatient ER visit9.1%12.3%12.0%better
Long-stay hospitalizations per 1,000 resident days1.212.171.67better
Long-stay outpatient ER visits per 1,000 resident days0.792.061.80better

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.

60.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 203 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

60.3%U.S. median 51.5%
Got home and stayed home
14.0%U.S. median 10.7%
Went back to hospital
57.1%U.S. median 56.6%
Met the expected recovery
0.64U.S. median 0.31
Therapy hours / resident / day
0.24hours / resident / day
Physical therapy
0.27hours / resident / day
Occupational therapy
0.13hours / resident / day
Speech therapy

Met the expected recovery: 57.1% 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 154 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 0.64 therapist hours per resident per day in 2026Q1 — more than 90% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 29% 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 SNF60.3%CMS range 52.9–68.751.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF14.0%CMS range 10.6–17.210.7%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 discharge57.1%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 discharge44.2%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 discharge50.6%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 identified85.0%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 setting95.2%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 discharge86.2%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 stay1.0%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 hospitalization9.6%CMS range 6.6–13.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.071.02Oct 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

0.58
RN hours/ resident / day
1.71
LPN hours/ resident / day
2.00
Aide hours/ resident / day
4.29
Total nurse hours/ resident / day
0.62
RN hoursweekends
41.8%
Total nursing turnover
35.7%
RN turnover

How full it usually is: this home is certified for 94 beds and averages 76.0 residents a day — about 81% occupied, or roughly 18 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 4.29 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.58 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.00 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.68 hrs/resident/day on weekends vs 4.53 on weekdays — 19% thinner on weekends. RN hours go from 0.56 to 0.62 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 42% 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

11
deficiencies at the latest standard inspection (2025-05-29)
6
at the previous standard inspection (2024-04-04)

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 10 most serious are shown; the remaining 19 are one tap away and print in full.

  • Potential for harm · D2026-04-02 · 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 consult with the physician regarding a change in condition for 1 (Resident #1) of 4 residents reviewed for change of condition.The facility did not consult with Resident #1's physician about his pattern of refusing to wear his CPAP (continuous positive airway pressure machine for the treatment of sleep apnea) on 2/22/26, 2/23/26, and 2/24/26; removing his oxygen by nasal canula at times; or his low oxygen saturation on 2/25/26.These failures could place residents at risk of having delayed treatments or worsening conditions.Findings included:Review of Resident #1's face sheet reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses in part including pulmonary edema (too much fluid in the lungs), sleep apnea (repeated stops and starts in breathing during sleep), and congestive heart failure (occurs when the heart can't pump blood well enough to give the body a normal supply).Review of Resident #1's Five-Day MDS 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-02 · 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 observation, interview and record review the facility failed to maintain clinical records that were complete and/or accurate for 1 (Resident #1) of 4 residents reviewed for clinical records in that: -The facility did not document a nursing assessment or progress note for Resident #1 when he refused his CPAP on 02/22/26 and 02/24/26.-The facility did not document a nursing assessment or progress note for Resident #1 when his oxygen saturation was low on 02/25/26. These failures could place residents at risk for wrong or missed diagnoses and/or treatments. Findings included: Review of Resident #1's face sheet reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses in part including pulmonary edema (too much fluid in the lungs), epilepsy (brain condition causing recurring seizures), sleep apnea (repeated stops and starts in breathing during sleep), and congestive heart failure (occurs when the heart can't pump blood well enough to give the body a normal supply).Review of…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-25 · 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 observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of hazards as was possible for 1 (Resident #2) of five residents reviewed for accident hazard. The facility failed to ensure that a container of germicidal (substance that destroys germs and microorganism) wipes was not left inside Residents #2's room on 10/07/2025. This failure could prevent the residents from having an environment that was free from toxic chemicals.Findings include: Record review of Resident #2's Face Sheet, dated 10/07/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with neoplasm (abnormal growth of tissue in the body) of the esophagus (hollow tube that carries food and liquid from the throat to the stomach). Record review of Resident #2's Comprehensive MDS Assessment (assessment used to determine functional capabilities and health needs), dated 09/02/2025, reflected the resident was cognitively intact…

    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 before2025-11-25 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for one (Residents #1) of eight residents reviewed for medication storage. The facility failed to ensure that Resident #1's collagen powder (medication used for wound care) for wound care was not inside the room on 10/07/2025. This failure could place residents at risk of misuse of medications that could lead to overdosing or underdosing.Findings include: Record review of Resident #1's Face Sheet, dated 10/07/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with pressure ulcer (wound on the skin caused by prolonged pressure to specific area of the body) of sacral (area at the bottom of the spine) region. Record review of Resident #1's Comprehensive MDS Assessment, dated 08/09/2025,…

    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 · E2025-05-29 · tag F0583 — failed to protect personal privacy — pattern
    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 observations, interviews, and record review, the facility failed to treat each resident with respect, dignity, and care in a manner and environment that promoted maintenance or enhancement of his or her quality of life for seven (Resident #195, Resident #200, Resident #193, Resident#202, Resident#65, Resident#16, and Resident #204) of sixteen residents reviewed for Privacy and Confidentiality. 1. The facility failed to ensure LVN C closed the door while flushing Resident #195's IV and disconnecting his IV bag on 05/27/2025. 2. The facility failed to ensure LVN D did not leave Resident #200, Resident #193, Resident #202, Resident #65, Resident #16 and Resident #204, medical information on top of the medication care unattended on 05/27/2025. These failures could place the residents at risk of not having their personal privacy maintained during medical treatment and their medical information exposed to unauthorized individuals. Findings included: 1. Record review of Resident #195'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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-29 · 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 residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 7 of 15 resident rooms on the 100 hall (Resident rooms #1, #2, #3, #4, #5, #6, and #7), and all the hand rails on the 500 hall, reviewed for environment. 1. The facility failed to ensure Resident rooms #1, #2, #3, #4, #5, #6, and #7 were thoroughly cleaned and sanitized. 2. The facility failed to ensure the handrails on the 500 hall were thoroughly cleaned and sanitized. These deficient practices could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings include: An observation on 05/27/25 at 11:00 AM of resident room [ROOM NUMBER] reflected the refrigerator in the resident room had brownish stains on the inside bottom of the refrigerator. The bathroom shower floor had a steel grill,…

    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 · E2025-05-29 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to ensure assessments accurately reflected the resident's status for three (Residents #196, #197, and #198) of sixteen residents reviewed for Accuracy of Assessments. 1. The facility failed to ensure Resident #196's Comprehensive MDS assessment dated [DATE] accurately reflected that the resident was on CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open). 2. The facility failed to ensure Resident #197's Comprehensive MDS assessment dated [DATE] accurately reflected that the resident was on oxygen therapy. 3. The facility failed to ensure Resident #198's Comprehensive MDS assessment dated [DATE] accurately reflected that the resident was on oxygen therapy. These failures could place the resident at risk for not receiving care and services to meet their needs, diminished function of health, and regression in their overall health. Findings included: 1. Record review of Resident #196's Face…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-29 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for six (Residents #29 #88, #193, #194, #197, and #198) of sixteen residents reviewed for Care Plans. 1. The facility failed to ensure Resident #29 was care planned for the resident's bed being placed in a low position and a fall placed alongside their beds for fall risk. 2. The facility failed to ensure Resident #88 was care planned for oxygen therapy on 05/09/2025. 3. The facility failed to ensure Resident #193 was care planned for CPAP on 05/17/2025. 4. The facility failed to ensure Resident #194 was care planned for catheter (flexible tube that collects urine from the bladder) when the resident was ordered to have 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-29 · 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 observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for six (Residents #88, #193, #196, #197, #198, and #244) of twelve residents reviewed for respiratory care. 1. The facility failed to ensure that Resident #88 had an order for continuous oxygen use. 2. The facility failed to ensure Resident #193's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs), breathing mask (used to receive medications by breathing in mist through nose and mouth), and CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) mask were properly stored when not in use on 05/27/2025 and that the resident had an order for CPAP and continuous oxygen. 3. The facility failed to ensure Resident #196's CPAP mask 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-29 · 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 the facility's only kitchen, reviewed for food and nutrition services. 1. The facility failed to place a cover on top of the tea dispenser to avoid air borne contaminants. 2. The facility failed to ensure prepared food in the dry storage, refrigerator and freezer was labeled and dated when stored. 3. The facility failed to ensure expired food in the refrigerator and freezer was discarded. 4. The facility failed to ensure all foods stored in the freezer and refrigerator was properly sealed. These failures could place residents at risk for cross contamination and air-borne illnesses. Findings include: Observations on 05/27/25 from 9:01 AM to 9:14 AM in the facility's only kitchen revealed: o Three trays containing small bowls of salads, located in a refrigerator, were not labeled with the date they were stored. Two large containers with small cups of white milk, located in the refrigerator, were 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 19 citations
  • Potential for harm · Ecited before2025-05-29 · 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 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 three (Resident #10, Resident #41 and Resident #195) of sixteen residents reviewed for Infection Control. 1. The facility failed to ensure CNA F performed hand hygiene and changed gloves while providing incontinent care to Resident #10 on 05/28/2025. 2. The facility failed to ensure CNA G performed hand hygiene and changed gloves while providing incontinent care to Resident #41 on 05/28/2025. 3. The facility failed to ensure LVN C wore a gown while flushing and disconnecting Resident #195's IV on 05/27/2025. These failures could place residents at risk of cross-contamination and development of infections. Findings included: 1. Record review of Resident #10's Face Sheet, dated 05/28/2025, reflected 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-29 · tag F0550 — failed to protect resident dignity and rights — isolated
    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 observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 2 of 12 residents (Resident #143 and Resident #194) reviewed for dignity. The facility failed to treat Resident #143 and Resident #194 with dignity and promote enhancement of their quality of life when the residents were not provided privacy bags for their catheter bags. This failure placed residents at risk of not having their right to a dignified existence maintained. Findings included: 1. Review of Resident #143's Face Sheet, dated 05/27/25, reflected a [AGE] year-old male admitted on [DATE]. Resident #143 was diagnosed with neuromuscular dysfunction of bladder (the muscles and nerves that control the bladder do not work properly due to illness). Review of Resident #143's Quarterly MDS Assessment, dated 05/09/25, reflected Resident #143 was cognitively…

    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 · D2025-05-29 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    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 residents were free from physical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms for 1 of 6 residents (Resident #17) reviewed for physical restraints. The facility failed to ensure Residents #17 had physician orders for the bolster pads on the mattress. This failure could prevent the residents from moving freely in and out of their beds and not from being restrained. Findings include: 1. Record review of Resident #17's Face Sheet, dated 05/28/25, reflected he was an [AGE] year-old male admitted on [DATE]. Relevant diagnoses included dementia (cognitive decline), and macular degeneration (loss of sight). Record review of Resident #17's Quarterly MDS assessment, dated 04/15/25, reflected he had a BIMS score of 14 (intact cognitive response). For ADL care, it reflected the resident required total assistance. Record review of Resident #17's physician orders,…

    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 · D2025-05-29 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure the resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance for 1 of 3 residents (Residents #1) reviewed for assisted nutrition and hydration. The facility failed to ensure Resident #1 was weighed monthly, according to her physician orders and her personalized care plan. This failure could prevent the facility from detecting if the resident was experiencing excessive weight loss. Findings include: 1. Record review of Resident #1's Face Sheet, dated 05/27/25, reflected she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included nutritional and metabolic disease, and muscle weakness. Record review of Resident #1's Quarterly MDS assessment, dated 02/19/25, reflected she had a BIMS score of 15 (intact cognitive response). For ADL care, it reflected the resident required supervision during eating. Record review of Resident #1's Physician…

    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 before2025-05-29 · 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 observations, interviews, and record review, the facility failed to ensure that drugs and biologicals were stored properly in locked compartments and under proper temperature for two (Cart #1 and Cart #2) of three nurses' carts observed for storage of drugs and biologicals. 1. The facility failed to ensure that LVN D locked Cart #1 before providing wound care to Resident #89 on 05/27/2025. 2. The facility failed to ensure RN A would not store Lorazepam (medication used to treat anxiety disorders) on Cart #2 on 05/28/2025. These failures could place the residents at risk of accessing/opening the cart causing accidental overdose or misuse of medications and not receiving the full benefit of the medication. Findings included: 1. Observation on 05/27/2025 at 12:02 PM revealed LVN D was about to do Resident #89's wound care. She prepared her dressing, gauzes, nasal saline bullets, and Iodoform packing strips. After preparing the things needed for wound care, she went inside the resident's room closed the door, and proceeded with wound care. She did not lock Cart #1 before going…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-04 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for three of (Resident # 14, Resident #48, and Resident #75) of six residents reviewed for Care Plans. The facility failed to ensure Resident #14 and Resident #75 were care planned for oxygen administration. The facility failed to ensure Resident #48 was care planned for CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open). These failures could place residents at risk of respiratory needs not being met. Findings included: Resident # 14 Review of Resident #14's Face Sheet dated 04/02/2024 reflected that resident was 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-04 · 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 observations, interviews, and record review, the facility failed to ensure that Residents, 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 four (Resident #77, Resident #14, Resident #48, and Resident #75) of ten residents reviewed for respiratory care. The facility failed to ensure Resident #77 and 48's nebulizer masks were properly stored. The facility failed to ensure Resident #14 and Resident 75's nasal cannulas were properly stored. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: Resident # 77 Review of Resident #77's Face Sheet dated 04/03/2024 reflected that resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included pneumonia and pneumonitis (inflammation of the lung tissues). Review of Resident #77's Comprehensive MDS assessment dated [DATE]…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-04 · 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 observations, interviews, 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 two (Resident #45 and Resident #29) of ten residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #45 and Resident #29'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 to get help in the event of an emergency. Findings included: Resident #45 Review of Resident #45's Face Sheet dated 04/02/2024 reflected that resident was a 53 -year-old male admitted on [DATE]. Relevant diagnoses included muscle weakness, acquired hammer toes (abnormal bending of the toe), and difficulty in walking. Review of Resident #45's Quarterly MDS assessment dated [DATE] reflected Resident #45 was cognitively intact with a BIMS score of 15. Resident #45…

    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 · D2024-04-04 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan was reviewed and revised by an interdisciplinary team for one (Resident #77) of six residents reviewed for revised Care Plan. The facility failed to ensure Resident #77's care plan was revised to reflect discontinued use of tube feeding. This failure could place the resident at risk of current needs not being met. Findings included: Review of Resident #77's Face Sheet dated 04/03/2024 reflected that the resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included stomatitis (inflammation of the mouth and lips) and dysphagia (difficulty in swallowing). Review of Resident #77's Comprehensive Care Plan dated 01/03/2024 reflected Resident #77 was still on tube feeding. Review of Resident #77's Comprehensive MDS assessment dated [DATE] reflected the resident was not able to complete the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-04 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in (1 of 1) kitchen reviewed for dietary services., in that: 1) Dietary staff failed to seal, label, and date refrigerator and freezer food items . 2) Dietary staff failed to remove items which have frost built up inside the container (bag). These failures could place residents at risk for food contamination and foodborne illness. The findings included: Inside the freezer on the left side of the door, had one case of breaded frozen chicken tenders that were open, leaving the patties exposed to contaminants and cold. Inside the freezer on the right of the door, had a stainless-steel bin which contained a gallon size bag of boneless pork chops. The pork chops were heavily freezer-burned, which would indicate a quality issue of the food item(s). During an interview with the Dietary Manager on 04/02/2024, between 9:30 a.m. and 10:05 a.m., a walk-through of the facility kitchen was performed, and 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-04 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based observations, interviews, 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 #1) of five residents observed for infection control. The facility failed to ensure that CNA B changed her gloves and performed hand hygiene while providing incontinence care to Resident #1. This failure could place the residents at risk of cross-contamination and development of infection. Findings included: Review of Resident #1's Face Sheet dated 04/03/2024 reflected resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included diarrhea, urinary tract infection, and a rash. Review of Resident #1's Comprehensive MDS assessment dated [DATE] reflected Resident #1 was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated Resident #6 was always incontinent 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-12-15 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility must ensure residents were free of any significant medication errors for one (Residents #1) of five residents reviewed for medications. LVN A failed to correctly transcribe the physician order of methotrexate sodium (medication for rheumatoid arthritis) for Resident #1 on 11/02/23, resulting in the resident receiving more medication than ordered. This failure could place residents at risk for not receiving therapeutic effects of their medications to include a diminished health status. Findings included: Review of Resident #1's clinical electronic record revealed the resident was a 74-old female admitted to the facility on [DATE]. The resident's diagnoses included syncope (fainting), urinary tract infection, chronic pain, muscle spasm and rheumatoid arthritis (chronic inflammatory disorder affecting joints). Review of Resident #1's admission MDS, dated [DATE], revealed Resident #1 had a BIMS score of 15, indicating resident was cognitively intact. Review of…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-02-16 · 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

    F-812 Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food safety in 1 of 1 kitchens reviewed. 1.The facility failed to ensure food located in the facility only kitchen refrigerator, dry food pantry, and prep areas were labeled and dated. 2.The facility failed to ensure that the dishing machine operating at the appropriate temperature for sanitation of the dishes. 3.The facility failed to ensure that staff covered used head and beard covering while conducting dietary duties. 4. The Faility failed to ensure dietary staff doffed used gloves when leaving the kitchen and donned new gloves when re-entereing the kitchen 5. The facility failed to ensure that the stove burners were clean and free of build up from oil, crumbs, waisted The facility failed to ensure the container for the tea covered and free of air borne substances. These failures could place residents at risk to bacteria, and other infectious illness. Findings include: During the initial tour of the facility's only kitchen…

    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 before2023-02-16 · 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, interviews, and record reviews, the facility failed to develop a care plan with measurable goals, and interventions to address the care and treatment for a resident with dementia for 1 of 6 residents (Resident #45) reviewed for Care Plans. The facility failed to ensure Resident #45's Dementia was care planned. This failure could place residents at risk of needs not being met. Findings include: Review of Resident #45's face sheet dated 02/15/2023 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included psychotic disturbance (Delusions), Dementia (Memory Impaired), Mood Disturbance (Depression), and Anxiety (Nervousness). Review of Resident #45's Minimum Data Set (MDS) dated [DATE], revealed a Care Area triggered for Resident #45 was Dementia. Review of Resident #45's Care Plan dated 02/15/2023, revealed the resident's last Quarterly Assessment was completed 11/23/2022. Interview on 02/15/23 at 1:35 PM with the DON revealed the resident was receiving…

    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 · D2023-02-16 · tag F0694 — isolated
    Provide for the safe, appropriate administration of IV fluids 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 parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 2 residents (Resident #119) reviewed for intravenous care. The facility failed to ensure Resident #119 received intravenous dressing changes to the PICC line at any time during his admission between 02/05/2023 and date of observation 02/14/2023. This deficient practice could place residents at risk of serious illness and/or infection. Findings included: Review of Resident #119's Face Sheet, dated 02/15/23, revealed he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included stroke resulting in paralysis affecting left side of his body, heart disease, streptococcus infection, and back surgery with disc replacement. Review of Resident #119's admission MDS, dated [DATE] stated he was moderately…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-16 · 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 is provided with such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #8) reviewed for respiratory care. The facility failed to ensure Resident #8 had oxygen concentrator filters free of sediment and debris. These failures could place residents at risk of not receiving proper delivery of oxygen, cross contamination, respiratory compromise and/or infection and residents not having their respiratory needs met. Findings Included: Review of Resident #8's Face Sheet, dated 02/15/23, revealed he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included chronic obstructive lung disease, respiratory failure, obstructive sleep apnea, pneumonia, morbid obesity, type 2 diabetes, swelling of extremities, mood disorder, obsessive-compulsive 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-16 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews the facility failed to ensure medications were secure and inaccessible to unauthorized staff and residents for one (400 Hall medication cart) of two medication carts. The facility failed to ensure medications were secure on the 400 Hall medication cart. These failures placed the residents at risk for drug diversion, drug overdose, and accidental administration of medications to the wrong resident. Findings included: In an observation on 02/14/2023 at 9:18 a.m., an unidentified white and blue capsule was observed in a plastic medication cup on top of the medication cart on the 400 hall. LVN Q was observed placing carbonated beverages in a refrigerator in room [ROOM NUMBER], outside of the view of the 400 Hall medication cart. At 9:19 a.m., LVN Q exited room [ROOM NUMBER] with cardboard boxes in her hands, and then disposed of the boxes. In an interview with LVN Q on 02/14/2023 at 9:40 a.m., she stated that Resident #9's roommate hollered and she left 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-16 · 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 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 #9) of five residents observed for infection control. 1. The facility failed to ensure LVN Q performed hand hygiene before and after administration of ophthalmic medications for Resident #9 on 02/14/2023. This failure placed residents at risk of cross-contamination and infections. Findings Included: Review of Resident #9's Quarterly MDS, dated [DATE] stated she was severely cognitively impaired with a BIMS score of 05. Resident #9 was totally dependent on one staff member for bed mobility, toileting, and personal hygiene. Record review of Resident #9's physician orders revealed Macrobid (nitrofurantoin monohyd/m-cryst) 50 mg capsule twice a day for urinary tract infection to start 10/20/2022. Additionally, 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2023-02-16 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    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 resident bedrooms measured at least 80 square feet per resident in multiple resident bedrooms for 57 (Rooms 101, 103, 104, 111, 112, 113, 114, 115, 201, 202, 205, 206, 207, 208, 209, 210, 302, 303, 304, 305, 306, 307, 309, 310, 311, 312, 313, 314, 601, 602, 604, 605, 606, 607, 609, 610, 611, 612, 701, 703, 704, 706, 707, 708, 709, 710, 801, 803, 804, 806, 807, 809, 811, 812, 813, 814, 815) of 101 resident bedrooms. The facility failed to ensure the following multiple resident bedrooms measured at least 80 square feet per resident: Rooms 101, 103, 104, 111, 112, 113, 114, 115, 201, 202, 204, 205, 206, 207, 208, 209, 210, 302, 303, 304, 305, 306, 307, 309, 310, 311, 312, 313, 314, 601, 602, 604, 605, 606, 607, 609, 610, 611, 612, 701, 703, 704, 706, 707, 708, 709, 710, 801, 803, 804, 806, 807, 809, 811, 812, 813, 814 and 815. This failure could at place residents at risk of not having adequate space for their personal belongings. Findings…

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

    Environmental 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 DALLAS COUNTY HOSPITAL DISTRICT — 5 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 53.0+1.0 vs chain
Health inspection 3 of 52.2+0.8 vs chain
Staffing 4 of 52.8+1.2 vs chain
Quality measures 5 of 54.6+0.4 vs chain
The other 4 homes this chain runs (chain average 3.0★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
CERISE, FREDERICKIndividualCORPORATE DIRECTORsince 03/24/2014
CASTANEDA, EDMUNDOIndividualCORPORATE OFFICERsince 01/10/2022
DALLAS COUNTY HOSPITAL DISTRICTOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2017
MILLENNIAL CARE MANAGEMENT, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2017
JOHNSON, TROYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/16/2004

CMS files one row per role, so the 6 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

$8.1M
Net patient revenuemost recent cost report
-12.7%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 43%Medicare 17%Other / private 40%

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$353per resident / day
operating cost
$10,740per month
≈ monthly operating cost
$314per 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 675136. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-29, 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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