Oasis Nursing & Rehabilitation Center
9001 N Loop, El Paso, TX 79907 · For profit - Corporation · 130 certified beds · (915) 859-1650 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high number of inspection citations overall (26) — 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 (95%) 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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 5 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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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.
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 | 18.2% | 15.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.2% | 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 | 0.0% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.6% | 2.4% | 6.5% | better than state‡ — see note marked double-dagger 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 | 3.9% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 3.0% | 14.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 8.8% | 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 | 1.6% | 3.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 12.7% | 13.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 1.9% | 9.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.2% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 88.0% | 79.4% | better |
‡ 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.
54.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 31 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.36 therapist hours per resident per day in 2026Q1 — more than 61% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 35% 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 | 54.7%CMS range 41.8–72.4 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.4%CMS range 6.7–15.8 | 10.7% | Oct 2022–Sep 2024 | no 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 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 | 90.9% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 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 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 | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 | 1.30 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 130 beds and averages 99.1 residents a day — about 76% occupied, or roughly 31 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.40 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.47 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.04 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 2.88 hrs/resident/day on weekends vs 3.61 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.50 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 95% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
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 fewer than at the previous inspection — improving. 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.
26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.
- Potential for harm · E2025-04-18 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents receive services in the facility with reasonable accommodation of resident needs and preferences for 2 (Resident #52 and Resident #88) of 9 residents reviewed for call light placement. The facility failed to ensure call lights were at reach for Residents #52 and #88. This failure could affect residents by not having access to call for assistance resulting in needs not being met. Findings included: Resident #58 Review of Resident #52's face sheet dated 04/17/2025 reflected an [AGE] year-old female with an admission date of 10/31/2022 and a re-admission date of 01/23/2025 with diagnoses of a fracture of unspecified part of the neck of right femur, pain on right hip, muscle wasting and atrophy, difficulty in walking, unsteadiness on feet, muscle weakness generalized and other lack of coordination. Review of Resident #52's quarterly MDS assessment dated [DATE] revealed a BIMS score of 9 indicating a moderate cognitive…
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 · E2025-04-18 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature, for one test tray reviewed. A test tray of the food served at lunch on 04/16/25 on hall revealed the ribs were not hot and at an appetizing temperature. This failure could place residents who ate in their rooms at-risk of poor intake and/or foodborne illness. The findings included: Observation of test tray provided to this surveyor on 04/16/25 at 12:32 PM, revealed temperature reading of lunch entree alternative ribs were 120F degrees. In an interview on 04/17/25 at 3:10 PM with Dietary [NAME] F revealed that hot food temperature readings should be 140F or 150F degrees at time of the resident is served. She stated the purpose for hot foods to be at that temperature was to satisfy the resident as they can become upset being served a cold meal when it was meant to be a warm meal. She stated the risks of hot food being below the required temperature included residents not eating their meals or harm such as illness. In 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 · Ecited before2025-04-18 · 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 observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the kitchen. The facility failed to date 04/15/25 and label the contents of the disposable plastic cups that contained syrup located in the fridge in the facility's main kitchen. The facility failed to maintain corn dogs and red onions free from visible freezer burn. The facility failed to maintain the water temperature for 2 of 3 compartment sink per their policy. The facility failed to maintain the kitchen area free from staff personal belongings. The facility failed to cover and seal a meal cart containing the residents' meal trays while transporting them through zone/hallway # 6. These failures could place all residents who received meals from the main kitchen and place them at risk for food borne illness. The findings were: In an observation on 04/15/25 at 07:09 AM during the initial kitchen tour, the fridge located in the main kitchen had disposable plastic cups that contained syrup that was placed in a plastic bin and was sealed…
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 before2025-04-18 · 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 drugs and biologicals were labeled in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions, and the expiration date for one of three medications carts reviewed. - The high north hall nurse's cart had a smeared (illegible) dated insulin pen for Resident # 58 This failure could place residents at risk for harm by receiving ineffective insulin therapy. Finding included: Review of Resident 58's face sheet dated [DATE] revealed a [AGE] year-old male with an original admission date of [DATE] and a readmission date of [DATE]. Review of Resident #58's medical diagnoses revealed Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema unspecified eye. Review of Resident #58's quarterly MDS assessment dated [DATE] revealed a BIMS score of 07, indicating severe cognitive impairment. Review of Resident #58's Care Plan dated [DATE] revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-02 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard 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 interviews and record review, the facility failed to maintain medical records that were complete and accurately documented for 5 (Resident #1, #2, #3, #4, and #5) of 5 residents reviewed for accurate medical records. 1. The facility failed to ensure LVN ADON C signed the Initial Skin Assessment when completed for Resident #1 on [DATE]. 2. The facility failed to ensure Social Worker signed and dated Care Plan Conference Form when completed for Resident #2 on [DATE]. 3. The facility failed to ensure Social Worker signed and dated Care Plan Conference Form when completed for Resident #3 on [DATE]. 4. The facility failed to ensure Social Worker signed and dated Care Plan Conference Form when completed for Resident #4 on [DATE]. 5. The facility failed to ensure Social Worker signed and dated Care Plan Conference Form when completed for Resident #5 on [DATE]. This failure could place residents at risk for misinformation about professional care provided. Findings included: Resident #1 Closed record review…
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 · D2024-04-02 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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, record review, and interviews, the facility failed to ensure that residents receive care, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 (Resident #5) of 5 residents reviewed for quality of care. The facility failed on 03/29/2024 to ensure the pressure ulcer on Resident #5's right lateral foot was covered with a dressing as ordered. This failure could result in increased pain, infections, development of new pressure ulcers, and decline in quality of life for residents. Findings included: Review of admission Record dated 03/29/24 at 12:39 PM, for Resident #5 revealed initial admission dated 11/02/2016 and re-admission date 05/16/2021. Record review of Annual History and Physical dated 07/20/2023 at 9:48 AM, for Resident #5 revealed [AGE] year-old male with past medical history of respiratory failure (a condition that makes it difficult to breathe on your own), vitamin D deficiency, hypertension,…
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 · D2024-02-08 · 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 and the facility failed to ensure the baseline care plan was developed within 48 hours of a resident's admission for 2 of 8 residents (Resident #294 and Resident # 241) reviewed for baseline care plans. The facility failed to ensure Resident #294 had a baseline care plan that addressed her fracture of left femur (longest, strongest, thigh bone), pain management, wound care for surgical wound, Type 2 Diabetes Mellitus, Hypertension (high blood pressure), and Malignant neoplasm of lung (lung cancer). The facility failed to ensure Resident #241 had a baseline care plan that addressed his use of a feeding tube. This failure could place residents at risk of not receiving needed care and services or continuity of care. Findings include: Record review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-08 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that residents who receive enteral nutrition received treatment to prevent complications of enteral feeding for one (Resident #241) of six residents reviewed for tube feeding. Resident #241 was receiving hydration through a g-tube (a tube into the stomach for nutrition and liquids) from a plastic bag which had been labeled using a marking pen. This failure could place residents who receive liquids through a g-tube at increased risk of having marking pen chemicals in the liquid. Findings included: Record review of Resident #241's face sheet, dated 2/8/2024 revealed he was [AGE] years old, was initially admitted to the facility on [DATE], and readmitted on [DATE]. Record review of Resident #241 ' s electronic census listing revealed he was discharged on 01/22/2024 and readmitted on [DATE]. Review of Resident #241 ' s electronic diagnoses listing accessed 02/08/2024 revealed he had diagnoses including dysphagia (problems with…
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 · D2024-02-08 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
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, interview and record review the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques to provide nursing and related services for 1 of 2 residents (Residents #27) by 1 of 3 certified staff (CNA A) reviewed for competent staff, in that: CNA A failed to change his gloves once they became contaminated during incontinent care for Resident #27. These failures could place residents at risk for not receiving nursing services by adequately trained and certified aides and could result in a decline in health and infection. The findings were: Record review of Resident #27s admission record dated 02/06/2024 indicated she was admitted to the facility on [DATE] with diagnoses of dementia, muscle wasting and atrophy (waste away). She was [AGE] years of age. Record review of Resident #27's care plan revised date 10/19/21 indicated in part: Focus: The resident has bladder incontinence r/t related to) Alzheimer's Disease and Dementia. The resident has bowel…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-08 · 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 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 2 residents (Resident #27) reviewed for infection control. CNA A failed to change his gloves after they became contaminated during incontinent care while assisting Resident #27. This failure could place residents at risk for cross contamination and the spread of infection. Finding include: Record review of Resident #27s admission record dated 02/06/2024 indicated she was admitted to the facility on [DATE] with diagnoses of dementia, muscle wasting and atrophy (waste away). She was [AGE] years of age. Record review of Resident #27's care plan revised date 10/19/21 indicated in part: Focus: The resident has bladder incontinence r/t Alzheimer's Disease and Dementia. The resident has bowel incontinence r/t Alzheimer's Disease…
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 16 citations
- Potential for harm · E2023-10-27 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 3 (Resident #7, Resident #8, and Resident #9) of 5 residents reviewed for quality of care. 1. The facility failed to ensure Residents #7's and #9's catheter leg strap was in place to secure the catheter. 2. The facility failed to ensure Resident #8's and Resident #9's'catheter tubing and drainage bags were off the floor. This failure could place residents with foley catheters at risk of catheter pulling causing pain and/or infection and risk for infection due to improper care practices and cross contamination. Findings include: Resident #7: Review of Resident #7's face sheet dated 10/26/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #7's diagnoses included: nontraumatic intracranial hemorrhage (bleeding into 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 · D2023-10-27 · 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 observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 (Resident #7) of 6 residents reviewed for resident rights, in that: The facility failed to ensure Resident #7's bedroom horizontal venetian blinds did not have several broken slats with jagged edges within reach of the resident. This failure could place the resident at risk of injury when manipulating the window blinds. Findings included: Review of Resident #7's face sheet dated 10/26/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #7's diagnoses included: nontraumatic intracranial hemorrhage (bleeding into the substance of the brain in the absence of trauma or surgery), cognitive communication deficit (difficulty with thinking and how someone uses language), hemiplegia affecting left nondominant side (paralysis of one side of the body), type 2 diabetes (a chronic condition that affects the way the body processes blood sugar),…
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 before2023-10-27 · 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 observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident medical and nursing needs and described the services to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 (Resident #7) of 6 residents reviewed for care plans in that: -The facility failed to follow the comprehensive person-centered care plan for risk of falling by applying a mat to bedside every shift for Resident #7. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services as indicated in their comprehensive person-centered plans developed to address their needs. Findings include: Review of Resident #7's face sheet dated 10/26/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #7's diagnoses included: nontraumatic intracranial…
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 before2023-01-05 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights,that included the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial need that were identified in the comprehensive for 3 of 13 residents (Residents #29, #186 and #41) reviewed for comprehensive person-centered care plans. 1. The facility failed to ensure positioning care for tube feeding was included in Residents #29 and #186 care plan. 2. The facility failed to ensure Resident #41's contracture of his right leg was addressed in the care plan. These failures could place residents at risk of not attaining or maintaining their highest practicable wellbeing, loss of range of motion and capacity to perform ADLs. Findings include: 1. Record review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-01-05 · tag F0688 — failed to keep residents mobile / prevent decline — patternProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that a resident who entered the facility without limited range of motion did not experience reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion was unavoidable and a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one of six residents (Resident #41) reviewed for range of motion. The facility failed to ensure Resident #41 did not develop a contracture of his right leg, which he did not have when he entered the facility. This failure could put residents at risk of decreased range of motion of their extremities thus reducing their quality of life and their capacity to care for themselves. Findings include: Record review of Resident # 41's Face sheet dated 01/05/2023, documented a [AGE] year-old male who was initially admitted to the facility on [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.
- Potential for harm · Ecited before2023-01-05 · tag F0693 — failed to provide proper feeding-tube care — patternEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 5 of 6 residents (Residents #70, #287, #29, #61 and #186) reviewed for gastrostomy tube care. The facility failed to ensure Resident #70, Resident #287, Resident #29, Resident #61, and Resident #186 were positioned at a 30-degree angle during enteral feeding. This failure could place residents at risk for aspiration, pneumonia, dehydration, and metabolic abnormalities which could result in additional treatment and a decline in the residents' health if not positioned correctly. Findings include: Record review of Resident #70's face sheet, dated 12/02/2022, indicated the resident was a [AGE] year old male admitted 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 · E2023-01-05 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews and record review the facility failed to follow menus for 1 of 1 resident meal (lunch) reviewed in that: The facility failed to ensure puree foods were prepared and met the number of puree residents who required puree meals. This deficient practice could place residents who consume food prepared by the facility kitchen at risk of having their nutritional status unmet. Findings include: Observation on 01/04/2023 at 10:00 a.m. revealed, Dietary Staff pureed carrots for 15 residents and did not yield 15 portions but instead 13 servings. Dietary staff scooped out 15 severing from a measuring 4-quart container into 8 inch deep well metal container. Dietary Staff used an ivory scoop to scoop out the portions from the mixture into another 8 inch deep well metal container. Staff counted out loud 13 servings. It was observed/heard staff tried again to recount and the outcome was the same with 13 scoops. Interview with Director of Food and Nutrition J on 01/05/2023 at 09:02 a.m., stated for the puree from yesterday (01/04/2023) he knew he did not come out with…
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 before2023-01-05 · 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 the 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 kitchen sanitation. 1. The facility failed to ensure food products in the dry storage area were correctly labeled and wrapped. 2. The facility failed to ensure foods products in the dry storage area were not expired. These failures could place residents at risk of food borne illness and malnutrition. Finding include: Observation on 01/03/2023 at 08:30 a.m. revealed, garlic bread packaged in the fridge sitting on the shelve was not labeled. Nuggets packaged in a big clear bag which sat on the shelve in the freezer were not labeled. The refrigerator had expired cilantro, dated 12/02/2022, that looked wet/slimy. Observation on 01/04/23 at 11:41 a.m. revealed, a whole apple pie cut was left on the steel counter and was not covered or dated. Two maintenance staff and other dietary staff passed by the uncovered pie. There was a bit of pie on a bowl that was not covered,…
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 · E2023-01-05 · tag F0840 — patternEmploy or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
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 obtain services furnished by outside resources in a timely manner one of six residents (Resident #49) reviewed for timeliness of services provided by outside resources. The facility failed to ensure Resident #49's physician's order to receive paracentesis (removing excess fluid from the abdomen) every two weeks was followed, and arrangements for paracentesis were not made in a timely manner. Which resulted in Resident #49 experiencing discomfort, difficult breathing, pain and increased anxiety. This failure could place residents at risk of not receiving treatments on a timely basis due to delays in having treatment arrangements made. Findings include: Record review of Resident #49's face sheet, dated 01/04/2023, documented a 61- year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included hepatic failure (liver failure), cirrhosis of the liver, acute kidney failure, end stage renal…
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 · E2023-01-05 · 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
Based on observation, interview and record review the facility failed to ensure it was adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area for 3 of 3 public restrooms reviewed for resident call systems. The facility failed to ensure 3 public restrooms, that were accessible to the residents, had a call light system. This failure could place residents at risk of being unable to obtain timely assistance for activities of daily living or in the event of an emergency. Findings include: During an observation on 01/05/23 at 10:50 AM revealed 1 public restroom on the south side of the facility and 2 public restrooms on the north side of the facility, 2 of the 3 restrooms were noted to be kept unlocked on several occasions. The restrooms did not have a call light system. These restrooms were in an area where residents had access to them. During an interview on 01/05/23 at 10:58 AM, RN E said he saw some resident's using the public restroom on the south side. RN…
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 · D2023-01-05 · 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 reviews 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, the residents' goals and preferences for 1 of 6 residents reviews for respiratory care. The facility failed to ensure an oxygen sign was hung outside of Resident's #289's room, who received oxygen. This failure could place resident(s) at risk of hazardous exposures such as explosions and being flammable that may led to physical harm. Findings include: Observation on 01/03/2023 at 09:08 a.m. revealed, Resident #289, in his room on in his wheelchair using oxygen. It was noted there was not sign posted outside of his room telling patients, staff, or visitors oxygen was in use. Interview with LVN F on 01/03/2023 at 9:13 a.m., LVN F stated the oxygen sign up on the side of the doors meant there was oxygen in use. LVN F stated every resident who used oxygen had to have one…
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 before2023-01-05 · 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
Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for one of two medication rooms (South side medication room) reviewed for medication storage. The facility failed to ensure the South Side medication room door was locked and supervised by staff. This failures could place residents at risk for having access to medications resulting in drug diversion or accidental ingestion. The findings included: During an observation and record review on 01/03/23 at 08:25 AM revealed the medication room door open and unattended in the south side nurses station. The medication room was noted to have several blister pack medications that included Donepezil (treats Alzheimer's disease), Memantine (treats Alzheimer's disease), Simvastatin (treat high cholesterol), Metformin (treats diabetes) and several other medications that belonged to different residents. There was a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-05 · 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 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 2 residents (Resident #18) reviewed for infection control. CNA A failed to change her gloves after they became contaminated during incontinent care while assisting Resident #18. This failure could place resident's at risk for cross contamination and the spread of infection. Finding include: Record review of Resident #18's admission record dated 01/03/23 indicated she was admitted to the facility on [DATE] with diagnoses of age related cognitive decline and muscle weakness. She was [AGE] years of age. Record review of Resident #18's quarterly MDS dated [DATE] indicated in part: BIMS = 08 indicating resident was moderately impaired. Urinary continence = always incontinent. Bowel continence = always incontinent. Record review…
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 · B2024-02-08 · tag F0640 — patternEncode each resident’s assessment data and transmit these data to the State within 7 days of 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 fulfill automated data processing requirements that within 14 days after a facility completes a resident's assessment, a facility must electronically transmit MDS data to the CMS System, including the subset of items upon a resident's discharge for 1 (Resident #83) of 24 residents reviewed for MDS completion. Resident #83's Discharge MDS dated [DATE] was not transmitted to CMS within the 14-day date processing requirement. This failure could place residents at risk of the CMS not being aware of their condition for payment and quality of measure purposes. Finding included: Record review of Resident #83's face sheet dated 02/08/2024 revealed he was 78 and was admitted to the facility on [DATE]. Record review of Resident #83's electronic census record revealed he was discharged on 10/11/2023. Record review of Resident #83's MDS transmittal information revealed his Discharge MDS had been completed but not transmitted to CMS. In an interview on 02/08/24 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2023-01-05 · tag F0575 — widespreadPost a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview the facility failed to post, in a form and manner accessible and understandable to residents and, resident representatives: a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the licensure office, adult protective services were state law provides for jurisdiction in long-term care facilities, and the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit for 1 of 6 (zone 6) halls reviewed for posting of required information. The facility failed to post a written description of a resident's legal rights in an accessible area for the residents, including information about pertinent state client advocacy groups such as the State Survey Agency and the Ombudsman. This failure could place residents at risk of lack of knowledge of who to contact should they require advocacy, investigation, and not knowing their rights or how to exercise…
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 · C2023-01-05 · tag F0577 — widespreadAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
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 post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility conducted by Federal or State surveyors, and failed to have reports with respect to any surveys made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request for one of three (2021) preceding surveys reviewed for survey results. The facility failed to ensure the facility notebook which contained the survey results from previous surveys contained reports for the survey of 10/21/2021 which included plans of corrections in effect. This failure could place residents at risk of not knowing corrective actions the facility was to take to address past deficiencies and violations. Findings include: Observation and record review on 01/05/2022 at 3:45 PM in the facility reception area revealed a binder labeled as containing recent survey outcomes.…
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 CREATIVE SOLUTIONS IN HEALTHCARE — 149 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 | 4 of 5 | 2.1 | +1.9 vs chain |
| Health inspection | 4 of 5 | 2.7 | +1.3 vs chain |
| Staffing | 1 of 5 | 1.1 | -0.1 vs chain |
| Quality measures | 5 of 5 | 3.2 | +1.8 vs chain |
The other 148 homes this chain runs (chain average 2.1★, per CMS)
Showing 40 of 148; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| BOWERS, SEAN | Individual | MANAGING CONTROL - GOVERNING BODY | since 07/01/2024 |
| CISNEROS, ALFRED | Individual | MANAGING CONTROL - GOVERNING BODY | since 02/18/2008 |
| COBB, TRAVIS | Individual | MANAGING CONTROL - GOVERNING BODY | since 10/05/2022 |
| COOPER, STEPHEN | Individual | MANAGING CONTROL - GOVERNING BODY | since 11/11/2022 |
| HARDIN, SHERRIE | Individual | MANAGING CONTROL - GOVERNING BODY | since 09/04/2024 |
| KERZEE, RICHARD | Individual | MANAGING CONTROL - GOVERNING BODY | since 09/24/2007 |
| KORENEK, PATRICIA | Individual | MANAGING CONTROL - GOVERNING BODY | since 05/05/2018 |
| SOECHTING, PAUL | Individual | MANAGING CONTROL - GOVERNING BODY | since 11/22/2024 |
| STRACK, JOE | Individual | MANAGING CONTROL - GOVERNING BODY | since 02/11/2022 |
| HUGGINS, LINDA | Individual | CORPORATE DIRECTOR | since 04/01/2022 |
| WILLIG, ZACHARY | Individual | CORPORATE DIRECTOR | since 01/01/2025 |
| THOMPSON, JOHNNY | Individual | CORPORATE OFFICER | since 01/01/2024 |
| EL PASO II ENTERPRISES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/16/2025 |
| BLAKE, GARY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/01/2022 |
| BLAKE, MALISA | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 09/01/2022 |
| AMAKIRI, ONYEMA | Individual | ADP OF THE SNF | since 01/01/2025 |
| SOLEM, DAVID | Individual | ADP OF THE SNF | since 05/16/2025 |
CMS files one row per role, so the 19 rows in the source record cover these 17 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.
1 organizational owner 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 79% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in TX
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 675568. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-18, 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.