Diboll Nursing and Rehab
900 S. Temple Dr, Diboll, TX 75941 · For profit - Corporation · 82 certified beds · (936) 829-5501 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (1/5)
- nursing-staff turnover (63%) 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 12.2% | 15.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.2% | 3.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.0% | 0.8% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.0% | 2.4% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.8% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 15.7% | 14.0% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 2.3% | 18.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.9% | 3.8% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 8.1% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 3.6% | 9.6% | 17.1% | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 1.02 therapist hours per resident per day in 2026Q1 — more than 97% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 22% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims 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 discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 82 beds and averages 25.6 residents a day — about 31% occupied, or roughly 56 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.94 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.32 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.50 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 2.72 hrs/resident/day on weekends vs 3.03 on weekdays — 10% thinner on weekends. RN hours go from 0.33 to 0.31 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 63% 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
Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
33 citations, most serious first. The 12 most serious are shown; the remaining 21 are one tap away and print in full.
- Immediate jeopardy · J2023-06-14 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to immediately consult with the physician of a significant change in the resident's physical, mental, psychosocial status; or a need to alter treatment significantly for 1 (Resident #35) of 8 residents reviewed for parameters to notify Physician of critical lab levels The facility failed to notify Resident # 35's primary care physician of critical low blood sugar readings of (46 mg/dl on 05/17/23 and 44mg/dl, on 05/21/23). The facility failed to train the staff of when to report changes to the physician. An Immediate Jeopardy (IJ) situation was identified on 06/13/23 at 3:00 PM. The IJ template was provided to the facility on [DATE] at 3:03pm. While the IJ was removed on 06/14/23, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy with a scope of isolated due to the facility's need to monitor and evaluate the effectiveness of their plan 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.
- Immediate jeopardy · J2023-06-14 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents ' choices for 1 of 8 residents (Resident #35), reviewed for quality of care. The facility failed to obtain orders for finger stick blood sugars for resident #35 and to follow their policy on Management of Hypoglycemia, (low blood sugar), when resident # 35's blood sugar reading was at critical levels of 46mg/dl on 05/17/23 and 44mg/dl on 05/23/23 and hold parameter for Insulin if blood sugar reading is at a critical level of below 70mg/dl. Resident #35 experienced sweating and shakiness when her blood sugar fell below 80mg/dl. Resident #35 had no orders for finger stick blood sugars and no parameters for holding Insulin for blood sugar levels below 70mg/dl. An Immediate Jeopardy (IJ) situation was identified on 06/13/23. The IJ template was provided to the facility on [DATE] at 3:03pm,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-08-27 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain personal hygiene for 4 of 8 residents (Residents #9, #1, #4, and #21) reviewed for ADL care. 1.The facility failed to clean/groom Resident #9's fingernails that had a dark brown substance underneath them on 8/25/25 and 8/26/25.2.The facility failed to trim, clean/groom Resident #21's fingernails that were about 1/2 inch in length and had a dark, brown substance underneath them on 8/25/2025.3. The facility failed to trim, clean/groom Resident #4's fingernails that were about 1/2 inch in length on 8/25/2025 and 8/26/2025.4. The facility failed to trim, clean/groom Resident #1's fingernails that were about 1/2 inch in length and had a brown substance underneath them on 8/25/2025 and 8/26/2025. These failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-08-27 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food safety requirements and kitchen sanitation.The facility failed to ensure all foods stored in the refrigerators were not kept past their expiration dates and were labeled and dated.The facility failed to ensure all foods stored in the dry storage area were not kept past their expiration dates.These failures could place residents at risk of foodborne illness and food contamination.Findings included: During an observation of the refrigerator on 8/25/2025 at 9:30 AM, the following items were observed:(1) 1 gallon container of unsweet tea dated 8/18/2025.(2) 1 gallon container of unsweet tea dated 8/19/2025.(3) 16 glasses of unsweet tea not labeled or dated.(4) 14 glasses of fruit punch not labeled or dated.(5) 2 glasses of orange juice not labeled or dated. During an observation of the dry storage area on 8/25/2025 at 9:30 AM, the following items were observed: (1) 5…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-08-27 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 3 of 5 residents (Resident's #1, #21, and #22) and 3 of 5 staff (CNA A, ADON and CNA E) reviewed for infection control. 1.The facility failed to ensure CNA A changed gloves and washed or sanitized her hands when providing care to Resident #21 on 8/25/2025.2. The facility failed to ensure ADON wore a gown during wound care to Resident #1 who was on enhanced barrier precautions on 8/26/2025.3. The facility failed to ensure CNA E wore a gown during incontinent care to Resident #22 who was on enhanced barrier precautions, and she failed to wash or sanitize her hands on 8/27/2025. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.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.
- Potential for harm · E2025-08-27 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident's medical record included documentation that indicates the resident received education on the influenza and the pneumococcal immunizations of 4 of 5 residents (Residents #1, #4, #7, and #21) reviewed for immunizations.The facility failed to document education was offered for the influenza and pneumococcal vaccinations to Residents #1, #4, #7 and #21.These failures could place residents at risk for contracting a viral disease that could spread through the facility and cause respiratory complications, and potential adverse health outcomes.Findings include: 1. Record review of a Face Sheet for Resident #1 dated 8/26/2025 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of pressure ulcer of sacral region stage 3 (wound a the bottom of the spine that extends through the skin and tissue), diabetes mellitus, and malignant neoplasm of upper lobe of lung (lung cancer). Record review of a comprehensive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-08-27 · tag F0919 — failed to provide a working call system — patternMake sure that a working call system is available in each resident's bathroom and bathing area.
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 could call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 4 of 6 residents (Residents # 6, #22, #26, and #27) reviewed for resident call system.1.The facility failed to ensure Residents #6, #22, and #26 had a call light within reach on 8/25/25 and 8/26/2025.2.The facility failed to ensure Resident #27 had a call light that was functional. Resident #27 did not have a pull cord attached to the call box on 8/25/25.This failure could place residents at risk for a delay in assistance and decreased quality of life, self-worth, and dignity. Findings included: 1.Record review of a facility face sheet dated 8/26/25 for Resident #6 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of Alzheimer's disease. Record review of a Comprehensive MDS assessment dated [DATE] 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.
- Potential for harm · D2025-08-27 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to provide a safe, clean, comfortable, and homelike environment 1 of 3 halls (room [ROOM NUMBER]) reviewed for environment.The facility failed to repair the window in Resident #8's room [ROOM NUMBER] that had a broken frame that was frayed and splintered on 8/26/2025 and 8/27/2025.This failure could place the residents at risk of living in an unsafe, unsanitary, and uncomfortable environment.Findings include:Record review of a face sheet for Resident #8 dated 8/26/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of severe intellectual disabilities (delay in language, motor, and social skills), expressive aphasia (difficulty speaking), and hypotension (low blood pressure). Record review of the maintenance log dated 7/30/2025 indicated that the window frame in Resident #8's room was reported and initialed by Maintenance. Record review of a care plan for Resident #8 dated 7/23/2025 indicated she 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.
- Potential for harm · D2025-08-27 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 requiring respiratory care are provided care, consistent with professional standards of practices for 1 of 5 residents reviewed for respiratory care (Residents #21).The facility failed to ensure the external filters of Resident #21's oxygen concentrators was free of dust build up from 8/25/2025-8/27/2025.These failures could place residents who require respiratory care at risk for respiratory infections, breathing in dust and allergens, decreased effectiveness of oxygen concentrators, and exacerbation of respiratory distress.Findings included:Record review of a Face Sheet for Resident #21 dated 8/26/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hemiplegia following cerebral infarction affecting left non-dominant side (paralyzed on left side of the body following a stroke), type 2 diabetes, heart failure (heart not able to pump effectively) and GERD (acid reflux).…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-27 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and follow a policy to provide pharmacy services in accordance with State and Federal laws or rules of the Drug Enforcement Administration for 1 of 5 months (February 2025) reviewed for pharmacy services. The facility failed to have 2 witness signatures on attached page of controlled substances at time of disposal on 2/11/25.This failure could put residents at risk for misappropriation and drug diversion.Findings include:Record review of facility drug destruction records dated August 2024 through August 2025 revealed that on February 11, 2025, the attached page containing controlled substances was signed by the consultant pharmacist and one witness, the DON, and did not contain 2 witness signatures as required.During an interview on 8/27/25 at 11:15 am the DON said she was responsible for drug destruction. She said she was unsure how the witness signature was missed on the attached sheet…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-27 · tag F0813 — isolatedHave a policy regarding use and storage of foods brought to residents by family and other visitors.
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 and ensure safe and sanitary storage of residents' food items for 2 of 5 resident personal refrigerators reviewed for food safety (Resident #3 and Resident #14).The facility failed to ensure the refrigerator for Resident #3 did not contain expired cheddar cheese bars or canned sausage. The facility failed to ensure the refrigerator for Resident #14 did not contain expired pineapple tidbits, fruit cups or pineapple juice. This failure could place resident at risk for food borne illnesses.Findings include:1.Record review of Resident #3's electronic medical record and face sheet undated reflected she was admitted to the facility on [DATE]. Her diagnoses included: radiculopathy, cervical region (pain, weakness or numbness), cellulitis and abscess of mouth (bacterial infection of the skin and the deeper tissues beneath the skin), psychotic disorder with hallucinations (severe mental illness with false perceptions of things not there…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-07-17 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for dietary services. 1. The Dietary Aide failed to properly wear hair net while in the kitchen on 7/15/2024. 2. Dietary Staff failed to check and log the dishwasher temperature and sanitation for month of July 2024. 3. Dietary Staff failed to properly label and dispose of leftovers from the refrigerator. 4. Facility staff failed to clean Resident #7's water pitcher. These failures could place residents at risk for food contamination and foodborne illness. Findings: During an observation on 7/15/24 at 6:45 am the dietary aide had hair out of his hair net on his neck and had facial hair with no beard guard net. During an observation on 7/15/24 at 6:50 am there was a dishwasher temperature and sanitation log located on the side of the refrigerator. The log had no temperatures or sanitation levels listed.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 21 citations
- Potential for harm · E2024-07-17 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record reviews, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 1 resident group (resident council) reviewed for quality of life. The facility failed to ensure that staff were not talking on their cell phones while providing care to residents. The facility failed to ensure that staff did not speak rudely to residents. This failure could place residents at risk of decreased feelings of self-worth. Findings include: During an anonymous group interview, 6 of 12 residents in attendance of resident council meeting voiced the following concerns: 1. Staff members had been providing care while using their personal cell phones. One resident said that a staff member had given her a shower recently and was on her cell phone using ear buds the entire time she showered her, and it made her feel very uncomfortable, almost like the person on the other end of the phone could…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-07-17 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 2 of 4 hallways (north hallway and south hallway) reviewed for environment, in that. 1. The nursing supply storage room on the south hallway was open and accessible to visitor or resident tampering/contamination of sterile products and supplies kept in the nursing supply storage room. 2. The shower room on the north hallway (100 hallway) was open and accessible to residents and staff staff allowing access to toxic cleaners. These failures could place residents at risk for unsafe environment resulting in injury or unsafe conditions due access to toxic cleaners and visitor or resident tampering/contamination of sterile products and supplies kept in the shower room and nursing supply room. Findings included: 1. During an observation on 07/15/2024 at 06:55 AM Nursing supply storage room on the end of the south hallway was observed to be open. Upon entrance to the nursing supply storage room there are…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-17 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of charges for those services, which included charges for services not covered under Medicare/Medicaid or by the facility's per diem rate for 3 of 3 residents (Resident #9, Resident #22 and Resident #139) reviewed for beneficiary notice. The facility failed to ensure Resident #9, Resident #22 and Resident #139 was given a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when discharged from skilled services at the facility prior to covered days being exhausted. This failure could place the residents who were discharged at risk of not having knowledge of changes to services in a timely manner to allow the resident or their representative the option of appealing the denial of services. Findings include: Record review of a facility face sheet dated 7/16/24 for Resident #9 indicated that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-17 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 7 residents (Resident #6) reviewed for care plans. The facility failed to develop a comprehensive care plan that included Resident #6's nutritional status and requirement of a feeding tube. This failure could place residents at risk of not having individual needs met and cause residents not to receive needed services. Findings: Record review of a facility face sheet dated 7/16/24 indicated Resident # 6 was an [AGE] year-old female that admitted on [DATE] with diagnosis cerebrovascular disease (reduction of blood flow in the brain). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #6 had a BIMS of 14 indicating intact cognition and required a feeding tube. Record review of a physicians consolidated order dated 6/28/24 indicated Resident #6 required Jevity C 1.5 at 65 ml (milliliters)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 1 of 7 residents (Resident #3) reviewed for accidents hazards and supervision, in that: CNA E and CNA F failed to properly transfer Resident #3 on 7/15/24. This deficient practice could result in a loss of quality of life due to injuries. Findings: Record review of a facility face sheet dated 9/16/2020 indicated Resident #3 was a [AGE] year-old female that admitted on [DATE] with diagnosis of Alzheimer's. Record review of a quarterly MDS assessment dated [DATE] indicated Resident # 3 had a BIMS of 11 indicating moderately impaired cognition and required total dependence of two persons for transfers. Record review of a facility comprehensive care plan dated 5/07/24 indicated Resident # 3 required a mechanical lift to transfer times two persons. During an observation on 07/15/24 at 10:15 AM CNA E and CNA F were observed transferring Resident #3. Both CNAs…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-17 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals were properly stored and inaccessible to unauthorized staff and residents for one resident (Resident #16) of six residents reviewed for medication storage. The facility failed to ensure topical medications and skin cleanser were stored in a manner to prevent possible diversion or contamination. This failure could place residents at risk for drug diversion and access to medications that could cause harm, sickness, or hospitalization. Findings included: Review of Resident #16's face sheet dated 07/14/2024 reflected an eighty-three-year-old female admitted on [DATE] with diagnoses that included: Senile Degeneration of Brain (gradual loss of thinking ability), Diaper dermatitis (skin rash to the diaper area) Pressure-induced deep tissue damage of right ankle, (open skin break on the right foot), and Pressure ulcer of left ankle, stage 3 (open skin break of the left ankle). During an observation 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.
- Potential for harm · Dcited before2024-07-17 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 2 of 12 residents (Resident #6 and Resident #27) reviewed for infection control. The facility failed to ensure the COTA (certified occupational therapy assistant) followed enhanced barrier precautions when she provided care to Resident #6 on 07/15/2024. The facility failed to ensure LVN (licensed vocational nurse) followed infection control precautions when she administered medications to Resident #27 on 07/26/2024. These failures could place residents at risk for cross contamination and infection. Findings: 1.Record review of a facility face sheet dated 07/16/2024 indicated Resident # 6 was an [AGE] year-old female that admitted on [DATE] with diagnosis cerebrovascular disease (reduction of blood flow to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-17 · tag F0908 — failed to keep essential equipment working — isolatedKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to maintain all essential equipment in safe operating condition, for 1 of 1 stove in the kitchen reviewed for essential equipment. The facility did not ensure the gas stove was in working order. One of six gas stove burners (back right) had excessive carbon buildup and the burner did not fully light on 7/16/2024. This failure could place residents who eat out of the kitchen at risk for injury and under cooked food. Findings: During an observation on 7/16/24 at 10:53 am, 1 of 6 burners on the stove located in the kitchen did not light completely. The burner had carbon build up to the right side of the burner. During an interview on 7/16/24 at 10:54 am [NAME] H said she was the cook for the day, and it was her first day back from a month break. She said she was not sure who was responsible for burners on the stove, but the cooks cleaned the covers and grill daily. She said that the burner not lighting correctly could cause an injury, During an interview on 7/16/24 at 11:15 am the maintenance director said he was 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.
- Potential for harm · F2023-06-14 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
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 use the services of a registered nurse for at least eight consecutive hours a day, 7 days a week for 5 of 5 months reviewed. (January 2023-May 2023) The facility did not have RN coverage for 4 days in January 2023. The facility did not have RN coverage for 17 days in February 2023. The facility did not have RN coverage for 17 days in March 2023. The facility did not have RN coverage for 3 days in April 2023. The facility did not have RN coverage for 2 days in May 2023. This failure could place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as an emergency care and disasters. Findings included: Record review of the CMS Payroll Based Journal report for the 2nd quarter of 2023 (January 1, 2023 through March 31, 2023) indicated there were no RN hours for the following dates: 01/03 (TU); 01/04 (WE); 01/05 (TH); 01/06 (FR); 01/07 (SA); 01/08 (SU); 01/09 (MO); 01/10 (TU); 01/11(WE); 01/12 (TH); 01/13 (FR); 01/16 (MO); 01/17 (TU);…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-06-14 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure that the designated individual responsible for the infection control program was certified in infection prevention . This failure has the potential to affect all 36 residents of the facility due to potential outbreaks infections. (There was no full time Infection Preventionist at the facility.) Findings include: During an interview on 6/13/2023 at 8:10 AM, the ADON said she had been employed at the facility for 3 weeks and was not a Certified Infection Preventionist. She said the facility did not currently have a DON/IP and the DON/IP's last day was 5/26/2023. She said if an infection control nurse was not certified they could have an outbreak of infections at the facility, and that could have an adverse effect on the 36 residents. During an interview on 6/13/2023 at 2:15 PM, the Regional Nurse said she had been employed with the company for 2 years and was not a Certified Infection Preventionist. She said she visited the facility a couple of days a week when she came. She said the facility had been without a DON/IP…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-06-14 · tag F0657 — failed to keep the care plan current — patternDevelop 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 interview and record review, the facility failed to review and revise the person-centered care plans to reflect the current condition for 3 of 5 residents of the facility (Residents #7, #17, and #18). The facility failed to ensure Residents #7, #17, and #18 care plans conferences and reviews were held quarterly. This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings: Record review of a face sheet for Resident #7 dated 6/13/23 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: cerebral infarction (stroke), dysphagia (trouble swallowing), and hypertension. Record review of a Quarterly MDS Assessment for Resident #7 indicated that she had a BIMS score of 9, indicating that she had moderately impaired cognition. Record review of Resident #7's medical record indicated that last care conference was held on 9/9/22. Record review of the facility 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.
- Potential for harm · E2023-06-14 · tag F0926 — failed to keep the home smoke-free / fire-safe — patternHave policies on smoking.
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 follow established policy regarding smoking, smoking areas, and smoking safety for 2 (back porch smoking area and gazebo smoking area) of 2 smoking areas. The facility failed to keep cigarette butts out of the plastic trash can containing paper and plastic in the smoking area (back porch smoking area), and there were no red metal trash cans (fire-proof) available for residents to extinguish their cigarettes. The residents were putting their cigarettes out on the bricks of the building at the exit door next to the laundry (Gazebo smoking area). The residents were then placing the cigarettes in a coffee can and plastic bleach container at the doorway. This failure could place residents who smoke at risk of physical harm, burns, fires and lead to an unsafe smoking environment. Findings included: Record review of the Face Sheet dated 06/13/23, indicated Resident #24, admitted to the facility on [DATE], was [AGE] years old with diagnoses of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-06-14 · tag F0940 — failed to train staff — patternDevelop, implement, and/or maintain an effective training program for all new and existing staff members.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to develop, implement, and maintain annually an effective training program for all new and existing staff consistent with their expected roles, that included but are not limited to the mandatory training topics of communication, resident rights, abuse, infection control, dementia, and behavioral health for 9 of 13 employees (ADON, LVN G, Activity Director, FSS, Rehab Director, TNA C, CNA D, CNA E, CNA F) reviewed for training. The facility failed to ensure required trainings were provided to: ADON, LVN G, Activity Director, FSS, Rehab Director, TNA C, CNA D, CNA E, and CNA F. These failures could place residents at risk of being cared for by staff who have been insufficiently trained. The findings were : Record review of the personnel file for the ADON indicated she was hired at the facility on 4/24/2023. She received training on abuse on hire. There was no record of trainings on communication, resident rights, infection control, dementia, or behavioral health. Record review of the personnel file for LVN G indicated she hired…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-14 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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 self-administer medications if the IDT determined that the practice was clinically appropriate for 1 of 1 resident (Resident #238) reviewed for medication self-administration. The facility failed to assess, obtain physician orders and IDT approval for Resident #238 to self-administer his own bolus G-tube feedings. This failure could place residents at risk of infection and aspiration. Findings include: Record review of a face sheet for Resident #238 dated 6/13/23 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Gastrostomy status (an opening in the stomach for feeding and treatment), viral hepatitis C without hepatic coma (a viral infection that causes liver inflammation, sometimes leading to serious liver damage), Malignant neoplasm of mandible (mouth cancer), Malignant neoplasm of head, face and neck (head and neck cancer), and Pneumonia (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.
- Potential for harm · D2023-06-14 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure an accurate MDS was completed for 1 of 15 residents reviewed for MDS assessment accuracy. (Resident #17) The facility incorrectly coded Resident #17 as having not received oxygen in previous 14 days while a resident on her MDS. This failure could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings Include: Record review of the facility face sheet dated 6/13/2023 for Resident #17 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: Unspecified dementia (A group of symptoms that affects memory, thinking and interferes with daily life), anxiety, Type 2 diabetes mellitus (insufficient production of insulin, causing high blood sugar), Shortness of breath, and Acute systolic (congestive) heart failure (when your left ventricle can't pump blood efficiently). Record review of a Quarterly MDS dated [DATE] for Resident #17…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-14 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 3 of 6 residents (Residents #21, #34, and #238) reviewed for baseline care plans. The facility failed to develop a baseline care plan or comprehensive care plan within 48 hours of admission for Residents #21, #34, and #238. These failures could place residents at risk of not receiving care and services to meet their needs. Findings include: Record review of Resident #21, #34, and #238's electronic medical records indicated no baseline care plans were implemented. Record review of a face sheet dated 6/14/23 for Resident #21 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: cerebral palsy (A group of disorders that affect movement, muscle tone, balance, and posture), type 2 diabetes…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-06-14 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 2 of 15 residents (Residents #7 and #34) reviewed for care plans. The facility failed to ensure Resident #7's care plan accurately reflected her hospice status. The facility failed to ensure Resident #34's care plan accurately reflected her ADL status. This failure could place residents at risk of not receiving appropriate care and interventions to meet their current needs. Findings include: Record review of a face sheet for Resident #7 dated 6/13/23 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: cerebral infarction, dysphagia, and hypertension. Record review of a Quarterly MDS assessment dated [DATE] for Resident #7 indicated that she had a BIMS score of 9, indicating that she 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.
- Potential for harm · Dcited before2023-06-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as is possible for 1 of 1 courtyard reviewed for accident hazards. The facility failed to store laundry detergent and bleach away from residents. These failures could place the residents at risk of accidents hazrds in the environment in which they live. Findings included: Record review of the Face Sheet dated 06/13/23, indicated Resident #24, admitted to the facility on [DATE], was [AGE] years old with diagnoses of End Stage Heart Disease (heart no longer pumps effectively), essential (primary) hypertension (high blood pressure) and Depress (mood disorder). Record review of a Quarterly MDS assessment for Resident #24 dated 4/27/23 indicated he had a moderate impairment in thinking with a BIMS score of 12 (A BIMS of 8-12 indicates the resident is moderately impaired.) During an observation on 6/12/2023 at 08:45 AM of the courtyard and smoking area revealed upon exit at the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-06-14 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and follow a policy to provide pharmacy services in accordance with State and Federal laws or rules of the Drug Enforcement Administration for 2 of 12 months (February 2023, and May 2023) reviewed for pharmacy services. The facility did not have a licensed pharmacist and two witnesses initial the attached pages of the controlled medication destruction inventory sheets. This failure could put residents at risk for misappropriation and drug diversion. Findings: During a record review of the facility's drug destruction log for the last 12 months (June 2022 to May 2023), revealed the drug destructions for controlled drugs dated 02/15/23 and 05/15/23 indicated that the attached pages of medication destruction were ot numbered and did not include the initials of the consultant pharmacist and two witnesses. During an interview on 06/13/23 at 9:50 a.m., the ADON said there was no DON currently…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-06-14 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #34) reviewed for infection control. TNA B failed to wash or sanitize her hands when changing gloves while performing incontinent care to Resident #34. TNA B failed to change her gloves when going from dirty to clean while performing incontinent care to Resident #34. This failure could place residents at risk of exposure to communicable diseases and infections. Findings included: Record review of an undated face sheet for Resident #34 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hemiplegia and hemiparesis following intracerebral hemorrhage (weakness on one side after a brain bleed), chronic kidney disease (loss of kidney function),…
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.
- No harm found · C2023-06-14 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS reviewed for administration (Fiscal year 2023 for the second quarter January 1, 2023 to March 31, 2022) The facility failed to submit accurate licensed nursing coverage 24 hours a day for 1/3/2023, 1/27/2023, 3/2/2023 and 3/7/2023. These failures could place residents at risk for personal needs not being identified and met. The findings included: Record review of the CMS PBJ report for the second quarter of 2023 (January 1, 2023 through March 31, 2023) indicated there was no licensed nursing coverage 24 hours/day for the following dates: 1/3/2027, 1/27/2023, 3/2/2023 and 3/7/2023. During an interview on 6/12/2023 at 2:00 PM, HR said she had been employed at the facility since August 2022. She said she was responsible for making sure hours were submitted to payroll.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to SLP OPERATIONS — 7 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.1 | -0.1 vs chain |
| Health inspection | 3 of 5 | 2.3 | +0.7 vs chain |
| Staffing | 1 of 5 | 1.1 | -0.1 vs chain |
| Quality measures | 4 of 5 | 4.0 | ≈ chain avg |
The other 6 homes this chain runs (chain average 2.1★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| SLP OMEGA OPERATIONS, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 06/01/2021 |
| SENIOR LIVING PROPERTIES LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/01/2021 |
| SLP MANAGEMENT HOLDINGS, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/01/2021 |
| SLP OPERATIONS, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/01/2021 |
| BOSWELL, DARREN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/01/2021 |
| EDEN, JAMES | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/01/2021 |
| WHITWORTH, GARY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/01/2021 |
| OHI ASSET (TX) DIBOLL, LLC | Organization | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | — | since 09/01/2020 |
| LEONARD, JOSHUA | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2024 |
| FAIRLEY, JAMES | Individual | ADP OF THE SNF | — | since 06/01/2021 |
| SPLENSER, PABLO | Individual | ADP OF THE SNF | — | since 09/01/2020 |
CMS files one row per role, so the 13 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.
5 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 83% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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
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
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 675907. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-27, 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.